Case Manager III (4345)

LIFELONG MEDICAL CARE•Oakland, CA

18d•Hybrid

About The Position

The Case Manager III (CM III) is a key member of the primary care interdisciplinary team, providing services for patients with complex care needs. This position involves patient outreach, engagement, psychosocial service assessment, and assisting in developing patient-centered care plans. The CM III leads the implementation of Enhanced Care Management (ECM) and coordinates service referrals and delivery. This role requires meeting clients in various settings such as home, clinic, or community, and often provides care outside of a traditional health center setting, including home visits, hospitals, supportive housing sites, encampments, and shelters. The CM III provides services to specific populations with multiple complex health and social services needs and offers comprehensive housing navigation support to clients.

Requirements

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
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 a Case Manager II or equivalent position or 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

Nice To Haves

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

Responsibilities

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
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