ECM and JI Services Lead Care Manager

Description

Position Overview:

The Lead Care Manager (LCM) is responsible for providing comprehensive case management to all populations of focus enrolled in the Enhanced Care Management (ECM) program at Bayview Hunters Point Foundation. The LCM facilitates access to and understanding of services and programs, helping members navigate the health and social services system to improve overall health and well-being. The ideal candidate is an energetic self-starter who works collaboratively within a multidisciplinary team and engages effectively with external partners and service providers.

• Serve as the primary contact for clients, coordinating care and communication with healthcare providers, social services, and caregivers.
• Conduct comprehensive health and psychosocial assessments to develop individualized, member-centered care plans.
• Oversee client goal setting and care plan development, ensuring plans address physical health, mental health, SUD, and other needs.
• Implement and monitor member care plans, educating clients and addressing barriers to care.
• Provide mental health promotion, social work services, crisis intervention, and connection to community resources.
• Assist clients in navigating health services, including arranging transportation and appointment scheduling.
• Ensure accurate and timely documentation of all services provided in accordance with Medi-Cal and Medicare billing requirements.
• Maintain up-to-date patient health records in the Electronic Health Record (EHR) and other business systems.
• Complete monthly reporting to ensure program compliance with funding and regulatory requirements.
• Monitor and adhere to billing procedures, ensuring alignment with state and federal regulations.
• Conduct outreach and engagement activities to connect with eligible members and log activity in the EHR system.
• Provide clinical guidance in implementing evidence-based practices, such as Motivational Interviewing and Trauma-Informed Care principles.
• Perform administrative tasks using HIPAA-compliant systems for remote work.
• Respect patient confidentiality and uphold HIPAA compliance.
• Attending training sessions, actively contributing to team development, and maintaining strong relationships with internal and external partners.
• Utilize video conferencing tools frequently for remote collaboration.
• Other duties as assigned.

• Education:
  
  Bachelor’s degree in Nursing, Social Work, Public Health, or a related field required. (Master’s degree preferred.)
• Experience:
  
  Minimum 3-5 years of case management experience. Experience in enhanced care management, healthcare, or social services is preferred.
• Licensure/Certification:
  Licensure as a Registered Nurse (RN), Licensed Clinical Social Worker (LCSW), or other relevant licensure preferred. Case management certifications (CCM, ACM) are desirable.
• Leadership
  
  Skills:
  
  Strong leadership, communication, and problem-solving skills, with the ability to manage and mentor a team effectively.
• Knowledge:
  In-depth understanding of care coordination, chronic disease management, behavioral health, social determinants of health, and community resources.
• Technical
  
  Skills:
  
  Proficiency in case management software, electronic health records (EHR), and data reporting tools.
• Preferred Qualifications:
  
  Experience working with high-need populations, including those with chronic illnesses, mental health conditions, homelessness, and substance use disorders.

• Mandated court reporting
• Regular and reliable job attendance.
• Effective verbal and written communication skills.
• Proficiency in computer skills, including knowledge of Microsoft Office, Avatar, internet browsers, etc.
• Exhibit respect and understanding of others to…