Case Manager II (4268

JOB SUMMARY

The Case Manager II (CM II), a key member of the primary care interdisciplinary team, provides services for patients with complex care needs. This position conducts patient outreach, engagement and psychosocial service assessment, assists in developing a patient-centered care plan, is the lead implementer of Enhanced Care Management (ECM) and coordinates service referrals and delivery. The Case Manager meets clients in home, clinic, or community as appropriate or required by the specific program/site.

The CM II provides services to specific populations that have multiple complex health and social services needs and often provides care outside of a traditional health center setting, such as home visits, hospitals, supportive housing sites, encampments and shelters.

• Outreach, via telephone and in person at Life Long, community and residential sites, to patients who meet case management program eligibility criteria or are prioritized by Life Long for this service
• Proactively meet and engage with patients to build effective relationships and assess strengths and needs through use of standard intake, screening tools, and health, and social services records review
• Actively involve patients and caregivers, as appropriate, in designing and delivering services, including development of care plans, assuring alignment with patients’ values and expressed goals of care
• Provide and facilitate referrals for internal and external resources, and collaborate with the patient to complete required applications, forms, or releases of information
• Maintain a patient caseload in accordance with Life Long standards for the specific population served or site requirements
• Utilize data registries and reports to manage caseload, meet program requirements, maintain grant deliverables, and promote high quality care
• Provide health education and training to patients, including but not limited to, harm reduction and disease risk-mitigation strategies that empower patients to manage their own health and wellness (e.g. overdose prevention, mitigating spread of communicable diseases)
• Assist patients with accessing and retaining public benefits and insurance (e.g. Medi Cal, SSI/SSDI, Cal Fresh, General Assistance, etc), and affordable/subsidized housing
• Respectfully and routinely communicate with patients, their care team members, external partners, and identified social supports
• Maintain knowledge of patients’ medical/behavioral health treatment plans and facilitate utilization of services by providing resources such as accompaniment, transportation, in-home care, reminder calls etc.
• Participate in team meetings to coordinate care, support patient goals, and reduce barriers to accessing services
• Advocate on behalf of patients to get their needs met and/or support patients to learn advocacy strategies for themselves.
• Provide case management services to patients with multiple complex acute or chronic medical or behavioral health conditions (e.g. HIV/AIDS, Hep C, congestive heart failure, severe diabetes, severe hypertension, psychosis, pregnancy, and homelessness)
• Provide general housing case management services that includes document readiness, housing problem solving, and assessments for Coordinated Entry System
• Assist with patient crisis intervention and de-escalation
• Provide and document billable services to eligible populations that result in revenue generation for Life Long
• Keep current on community resources and social service supports to effectively serve the target population
• Document patient contacts/services in required data systems (EHR, HMIS etc.) according to Life Long policy
• Specific activities may vary depending on the requirements of the program and funder.
• Promote diversity, equity, inclusion, and belonging in support of patients and staff
• Represent Life Long positively in the community and advocate on behalf of underserved populations

• Commitment to working directly with low-income persons from diverse backgrounds in a culturally responsive manner
• Commitment to harm reduction, recovery, housing first, age-friendly and patient centered care
• Strong organizational, administrative and problem-solving skills, and ability to be flexible and adaptive to change while maintaining a positive attitude
• Excellent interpersonal, verbal, and written skills
• Ability to prioritize tasks, work under pressure, and complete assignments in a timely manner
• Ability to seek direction/approval on essential matters, yet work independently, using professional judgment and diplomacy
• Works well in a team-oriented environment
• Conducts oneself in external settings in a way that reflects positively on your employer
• Ability to be creative, mature, proactive, and committed to continual learning and improvement in professional settings

• High School diploma or GED
• At least two (2) years of progressively responsible work or volunteer experience in a community-based health care or social work setting or at least one (1) year of…