Case Manager II (4268)

LIFELONG MEDICAL CARE•Berkeley, CA

1d•Hybrid

About The Position

The Case Manager II (CM II) is a vital part of the primary care interdisciplinary team, dedicated to serving patients with complex care needs. This role involves patient outreach, engagement, and psychosocial assessments. The CM II assists in creating patient-centered care plans, leads the implementation of Enhanced Care Management (ECM), and coordinates the referral and delivery of services. The position requires meeting clients in various settings, including homes, clinics, and community locations, as dictated by program requirements. The CM II specifically supports populations facing multiple, complex health and social service challenges, often extending care beyond traditional health center environments to include home visits, hospitals, supportive housing, encampments, and shelters. This role is represented by SEIU-UHW, with salaries and benefits governed by a collective bargaining agreement (CBA). Employees in this position must maintain good standing within SEIU-UHW as per the CBA.

Requirements

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 experience as a Case Manager I or equivalent position
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
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

Nice To Haves

Bachelor’s Degree in Social Work, or another Health or Human Services field
Work or lived experience in area(s) relevant to the population to be served: e.g. perinatal, homelessness, recovery, criminal justice, elder care, palliative and end-of-life care, or behavioral health

Responsibilities

Conduct outreach via telephone and in-person at LifeLong, community, and residential sites to patients eligible for case management programs or prioritized for service.
Engage proactively with patients to build relationships and assess strengths and needs using standard intake, screening tools, and review of health and social services records.
Involve patients and caregivers in designing and delivering services, including care plan development, ensuring alignment with patient values and goals.
Provide and facilitate referrals to internal and external resources, assisting patients with required applications, forms, or releases of information.
Manage a patient caseload according to LifeLong standards for the specific population served or site requirements.
Utilize data registries and reports to manage caseloads, meet program requirements, maintain grant deliverables, and enhance care quality.
Provide health education and training to patients, including harm reduction and disease risk-mitigation strategies (e.g., overdose prevention, communicable disease spread mitigation).
Assist patients in accessing and retaining public benefits and insurance (e.g., MediCal, SSI/SSDI, CalFresh, General Assistance) and affordable/subsidized housing.
Communicate respectfully and regularly with patients, care team members, external partners, and social supports.
Maintain knowledge of patients’ medical/behavioral health treatment plans and facilitate service utilization through resources like accompaniment, transportation, in-home care, and reminder calls.
Participate in team meetings to coordinate care, support patient goals, and reduce barriers to accessing services.
Advocate for patients to ensure their needs are met and support patients in developing their own advocacy skills.
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).
Offer general housing case management services, including document readiness, housing problem-solving, and assessments for the Coordinated Entry System.
Assist with patient crisis intervention and de-escalation.
Provide and document billable services to eligible populations to generate revenue for LifeLong.
Stay current on community resources and social service supports to effectively serve the target population.
Document patient contacts and services in required data systems (EHR, HMIS etc.) according to LifeLong policy.
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.