Clinical Case Manager, LCSW

Overview

Marin Community Clinics, founded in 1972, is today, a multi-clinic network with a wide array of integrated primary care, dental, behavioral, specialty and referral services. As a Federally Qualified Health Center (FQHC), we provide vital health services to almost 40,000 individuals annually in Marin County. The Clinics regularly receive national awards from the Health Resources and Services Administrations (HRSA). Our Mission is to promote health and wellness through excellent, compassionate care for all.

Marin Community Clinics is looking for a mission-driven Clinical Case Manager, LCSW - Older Adults to join our dynamic, multidisciplinary, Complex Care team to advance our goal of improving health outcomes for older adults with complex medical, behavioral health, and psychosocial needs. At MCC we understand that as our older adult patients’ healthcare needs change over time, they experience unique barriers to wellness.

The Clinical Case Manager, LCSW - Older Adults will provide a whole-person approach to physical and mental wellness by providing case management and Behavioral Health support to a panel of patients. Working collaboratively with primary care and other members of the clinical care team, the Complex Care Case Manager, LCSW - Older Adults works as a member of an expert team of professionals to provide patient-centered, outcome- driven care that promotes independence and dignity.

The Case Manager will report to the Director of Complex Care.

We are looking for a Case Manager who:

• Understands the interplay between chronic conditions and psychosocial issues.
• Understands the unique needs and challenges experienced by older adults,
• Is comfortable working with individuals with complex behavioral health presentations and/or substance use disorders.
• Has passion for helping individuals navigate a complex system of care.
• Is a team player and welcomes guidance from multidisciplinary team members.
• Demonstrates initiative, creativity, and enjoys problem solving.
• Is comfortable working with community partners including community-based organizations (CBOs), Marin County, medical/BH specialists, and insurance providers.
• Ascribes to the tenets of person-centered, trauma-informed, housing-first care.
• Demonstrates compassion and respect for individuals served in all interactions.
• Has excellent organizational skills.
• Demonstrates a willingness to be flexible and adaptable in all aspects of this work.
• Experience/familiarity with housing resources/housing navigation in Marin is highly preferable.

• Support a caseload of 30-40 Complex Care patients.
• Develop a comprehensive patient care plan in partnership with patients.
• Assist patients to coordinate all necessary care.
• Provide targeted BH support and interventions as appropriate.
• Triage and respond to tasks/care needs.
• Work with Patients to address social determinants of health (SDOH) and other barriers to care.
• Support patients in connecting to community resources.
• Assist patients in navigating a complex healthcare system.
• Conduct home/community visits as needed.
• Consult/coordinate with interdisciplinary care team, including behavioral health, care navigation MAs, nursing, medical providers, and external partners.
• Attend internal and external meetings (i.e. case conferencing, administrative).
• Attending trainings such as health coaching, engagement techniques, etc.
• Timely and accurate reporting of data as requested to MCC CM programs.
• May travel between clinics or meet Patients in the community as needed.
• Provide frank and considered opinions regarding case management services and quality improvement measures.
• Provide services to satellite clinics as needed; may be asked to work variable schedule during extended-hour clinics (e.g., 10am-7pm on one or more days).
• Other duties may be assigned.

Education and Experience:

• Must be a Licensed Clinical Social Worker (LCSW) with valid California State License.
• 1-2 years’ experience (and passion for) providing support to individuals with chronic and complex BH needs, complex medical conditions and/or substance-using individuals highly preferable.
• Experience working with aging adult population highly…