Complex Care - Team Lead

Marin Community Clinics•Novato, CA

3d•Hybrid

About The Position

Marin Community Clinics, founded in 1972, is a multi-clinic network offering integrated primary care, dental, behavioral, specialty, and referral services. As a Federally Qualified Health Center (FQHC), it serves almost 40,000 individuals annually in Marin County, with a mission to promote health and wellness through excellent, compassionate care for all. The Complex Care Team Lead role aims to improve health outcomes for individuals with complex medical, behavioral health, and psychosocial needs. This position involves collaboration with primary care, behavioral health, and other clinical team members, providing leadership and support to Associate Case Managers to ensure high-quality patient care and staff satisfaction. It is a patient-facing role focused on engagement and building trust with complex patients. The ideal candidate will have experience serving complex care patients, particularly those experiencing homelessness, adverse experiences, and complex medical conditions, and will demonstrate initiative in program development, leadership in Complex Care, effective feedback skills, and excellent coalition-building abilities with community partners. They should be comfortable working with individuals with complex behavioral health presentations and/or substance use disorders, possess excellent organizational skills, and have a passion for helping individuals navigate complex care systems. The role requires a team player who welcomes multidisciplinary guidance, demonstrates initiative, creativity, and problem-solving skills, and adheres to person-centered, adverse experiences-informed, housing-first care tenets, showing compassion, respect, flexibility, and adaptability.

Requirements

1 year experience in case management healthcare setting.
1 year experience in a healthcare setting.
Completion of Lay Counselor Academy or equivalent certification/training.
Knowledge of state regulations and legal/ethical standards related to patient rights, and client/patient confidentiality required.
Must be fluent in English with the ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.
Ability to write reports and business correspondence in English.
Must be able to communicate with patients and partners in Spanish: effectively present information and respond to questions from clients, customers, and the public in Spanish.
To perform this job successfully, an individual must be computer literate and knowledgeable in Microsoft Office software programs, and how to conduct searches on the Internet.
Current BLS Certificate.
Valid Driver's License.

Nice To Haves

1-2 years’ experience (and passion for) providing support to individuals with chronic and complex BH needs, complex medical conditions and/or substance-using individuals.
Knowledge/experience with CalAIM ECM initiatives.
Training in motivational interviewing.
Candidate that can conduct clinical assessment interviews and case management interventions with patients in Spanish.

Responsibilities

Works closely with a team of Associate Case Managers to ensure the delivery of high-quality, equitable, person-centered case management to MCC patients.
Will complete new -patient assessments with Associate Case Mangers to ensure quality.
Ensures robust onboarding and ongoing training/education for Associate Case Managers.
Works closely with the Complex Care Clinical Supervisor for ongoing program development.
Maintains expertise in Complex Care initiatives like CalAIM/ECM.
May participate in interviewing/hiring staff.
Facilitate internal and external case conferencing.
Attend meetings with critical external partners.
Provide program development support (creating workflows, grant participation, program evaluation, etc.).
Ensure program reporting requirements and quality measures are met.
Maintains a caseload of up to 15 patients.
Conduct home/community visits as needed.
Document all Patient interactions and services using MCC’s electronic health record AND secondary database.
Attend internal and external meetings (i.e., case conferencing, administrative).
Attend relevant trainings such as health coaching, engagement techniques, etc.
Timely and accurate reporting of data as requested to MCC CM programs.
May travel between clinics or meet patients in the community as needed.
Provide frank and considered opinions regarding case management services and quality improvement measures.
Other duties may be assigned (including maintaining small caseload).