Chronic Care Case Manager, Lead

La Clinica de La Raza • Oakland, CA

3d

About The Position

La Clínica de La Raza is seeking a Lead Chronic Care Case Manager to support patient-centered care in a community health center serving diverse communities across the San Francisco Bay Area. The role focuses on chronic care management, patient health coaching, registry and panel management, quality improvement, and coordination with providers and other care team members. The posting describes the position as part of a fast-paced clinic environment and emphasizes accuracy, reliability, problem-solving, cultural responsiveness, and a supportive approach to patients and colleagues.

Requirements

• Valid license to practice as a Vocational Nurse in California.
• One to two years of experience in an outpatient facility working with adults and children.
• Current BLS (Basic Life Support) Certificate; a 30-day grace period from the date of hire is provided to obtain it.
• Experience working with patients in health promotion, with knowledge of medical terminology, chronic health conditions, and health coaching.
• Bilingual English/Spanish required.
• Ability to protect and maintain strict confidentiality and accurate, detailed patient medical information.
• Ability to work across cultures and demonstrate support for diversity, equity, and inclusion.
• Ability to work independently, exercise good judgment, and collaborate effectively with teams.
• Ability to work courteously and effectively as a team member in support of clinic quality and efficiency standards.
• Proficiency managing patient databases and using computer software such as Excel, Outlook, and practice management systems.

Nice To Haves

• Knowledge of the chronic care model, fundamentals of health education, motivational interviewing, and supporting patients with self-assessment goals.

Responsibilities

• Participate in health coaching, including supporting medication adherence, counseling patients on healthy behaviors, helping patients with self-management goals, and making referrals to healthcare services.
• Update and maintain patient registries and tracking systems for provider panels and conditions such as HIV, hypertension, diabetes, and coronary artery disease.
• Assist in training and supporting Medical Assistants in panel management.
• Review registries for target populations and panels, conduct interventions agreed upon by the healthcare team, and perform coach visits with patients while following adherence guidelines and documentation requirements.
• Provide feedback and progress reports to Site Improvement Teams on panel health status and outcomes.
• Collaborate with healthcare team members, including health educators or BMS, to support individual or group-based care interventions.
• Enter data and maintain the integrity of patient registries by cleaning data, running periodic reports, and confirming electronic registry accuracy.
• Carry out provider and healthcare team orders consistent with the employee’s level of training, including ordering labs, performing INRs and A1C testing, scheduling appointments, coordinating referrals, and conducting health coaching visits, potentially using standing orders for common problems.
• Attend section meetings and other meetings that support the job responsibilities.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Education Level: No Education Listed