Case Manager IV

JOB SUMMARY:

The Case Manager IV (CM IV), 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 IV 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. In addition they provide comprehensive housing navigation support to clients. The Case Manager IV is distinguished by their role in relation to other case managers on the team and program operation including providing case manager onboarding and training, using data to support caseload management and quality assurance, and involvement in quality improvement and other projects.

This position is represented by SEIU-UHW. Salaries and benefits are set by a collective bargaining agreement. (CBA), and an employee in this position must remain a member in good standing of SEIU-UHW, as defined in the CBA.Essential Functions 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), 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 reducing barriers to accessing services

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 Assess patients to identify cognitive and/or behavioral health needs and provide brief interventions and short-term support using standardized tools and effective approaches for patient care

Co-facilitate patient groups

Provide intensive case management to a caseload size in accordance with site or program standards focusing on a subset of the highest acuity patients

Provide specialized housing navigation services to patients who are matched to a housing resource through Coordinated Entry System Lead crisis intervention response, de-escalation procedures, notification of the local mental health department and/or crisis response team, and follow-up care Provide and document billable services to eligible populations that result in revenue generation for Life Long Develop  and maintain onboarding documentation pertinent to the Case Manager role Provide training and onboarding support to new Case Managers according to program policy and procedure and under supervisor’s guidance and oversight

Provide ongoing technical assistance and subject matter expertise through consultation and case conferencing

Coordinate special projects assigned by site or program Leadership Assist with triaging caseloads using data tools to identify patients and prioritize…