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 CM IV provides day-to-day support of this SAMHSA funded project, including coordination of SUD/COD counseling and case management services at various sites in the community. They work with the Project Director/Program Manager to lead new hire onboarding, staff training, case consultation, and support to triage caseloads. This project is housed at our homeless services drop-in center, Our Place, in West Oakland that provides comprehensive hygiene, nutrition, peer support, behavioral health, and medical care to people who are or have experienced homelessness.

This is a grant funded, full time, benefit eligible opportunity. 

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.

LifeLong Medical Care is a multi-site, Federally Qualified Health Center (FQHC) with a rich history of providing innovative healthcare and social services to a wonderfully diverse patient community. Our patient-centered health home is a dynamic place to work, practice, and grow. We have over 15 primary care health centers and deliver integrated services including psychosocial, referrals, chronic disease management, dental, health education, home visits, and much, much more. 

Benefits

Compensation: $32.15 - $35.13/hour. We offer excellent benefits including: medical, dental, vision (including dependent and domestic partner coverage), generous leave benefits including ten paid holidays, Flexible Spending Accounts, 403(b) retirement savings plan.

• Outreach, via telephone and in person at LifeLong, community and residential sites, to patients who meet case management program eligibility criteria or are prioritized by LifeLong 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 LifeLong 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. MediCal, SSI/SSDI, CalFresh, 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 LifeLong
• 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 outreach, screenings, and follow up activities
• Mentor and coach Case Managers, Interns, Apprentices, and Volunteers
• Assist in implementation of quality improvement and quality assurance efforts
• Assist in development and implementation of new workflows pertinent to the Case Manager role
• The CM IV is not a management position and is not responsible for supervisorial tasks
• Advocate on behalf of patients to get their needs met and/or support patients to learn advocacy strategies for themselves.
• 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 LifeLong 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 LifeLong 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

Job Requirements          

• High School diploma or GED
• At least three (3) 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 experience as either a Case Manager II or Case Manager III or equivalent position and registration or certification as a Certified Alcohol and Drug Counselor by one of the two certifying bodies in California
• Proficient skills using Microsoft Office applications like Word, Excel, and Outlook, as well as the ability to work in and/or manage databases
• Access to reliable transportation with current license and insurance
• Manage and analyze data for patient management and quality improvement
• Strong track record of meeting program requirements including productivity and documentation timeliness
• Experience training, coaching and mentoring
• Project management experience
• Strong problem-solving skills

Job Preferences

• Bachelor’s Degree in Social Work, Health or Human Services field
• Lived experience of homelessness, incarceration, foster care, mental health services, substance use services or addiction, or as a close family member of someone who has this experience