ECM and JI Lead Care Manager (LVN)

Bayview Hunters Point Foundation•San Francisco, CA

5d•Onsite

About The Position

The ECM and JI Services Lead Care Manager (LVN) provides comprehensive, member-centered case management to members enrolled in Bayview Hunters Point Foundation’s Enhanced Care Management (ECM) program, including members eligible for Justice-Involved (JI) Services. The role carries a direct-service caseload of up to 50 members, supports access to health and social services, and collaborates with internal staff, healthcare providers, caregivers, and community partners to improve members’ health and well-being. The position reports directly to the ECM and JI Services Program Manager. The Lead Care Manager conducts assessments, develops and monitors individualized care plans, coordinates services, and provides outreach, engagement, and support to members. The role includes meeting scheduled in-person visit and monthly billable-encounter targets, ensuring members receive all seven ECM core service components, and tailoring services to the needs of the JI population. Some weekend work may be needed to support members during events such as emergency room admissions. The position requires timely and accurate documentation in the Electronic Health Record (EHR) and other systems, compliance with Medi-Cal, Medicare, CalAIM, CARF, and billing requirements, regular self-audits, and monthly reporting. Work is onsite and field-based in San Francisco, California. The employee must follow HIPAA requirements and BVHPF’s Lone Worker Policy, including use of an assigned personal safety device during field work.

Requirements

Current State of California LVN license in good standing and required professional liability insurance.
Bachelor’s degree in Nursing, Social Work, Public Health, or a closely related field.
Three to five years of direct case management experience, including demonstrated ability to manage complex caseloads and coordinate services across systems.
Working knowledge of care coordination, chronic disease management, behavioral health integration, social determinants of health, and relevant community-based resources.
Familiarity with ECM and JI populations of focus, including understanding the distinction between justice-involved and justice-impacted individuals and how it affects service delivery.
Ability to use case management software, EHR systems, and data reporting tools accurately and consistently.
Strong written and verbal communication skills, organizational practices, and ability to work in a multidisciplinary team.
Ability to work respectfully and effectively with people from diverse cultural, linguistic, and socioeconomic backgrounds, including underserved, immigrant, and minority communities.
Flexibility, initiative, and ability to function proactively as a team member and work independently while seeking supervision when appropriate.
Strong organizational skills, including prioritization, multitasking, and meeting deadlines.
Dependability, adaptability, ability to work under pressure, receptiveness to change, and cooperation in problem-solving situations.
Regular and reliable job attendance.
Computer proficiency, including Microsoft Office, Avatar, and internet browsers.
Professional respect and understanding of others, sound independent judgment, and ability to make appropriate decisions.
Ability to work in an open office with moderate noise and distractions and meet deadlines with time constraints.
Ability to sit frequently, walk and stand occasionally, and travel from the building to other sites; vision abilities include close vision, distance vision, depth perception, and adjusting focus.
Ability to occasionally work irregular or extended hours.
Valid California driver’s license if duties require.
Ability to meet applicable state, federal, local, and BVHP standards.
Live Scan fingerprinting and TB clearance, as well as other medical vaccinations, may be required.
Selected candidates are subject to comprehensive background check clearance in accordance with applicable laws and regulations.

Nice To Haves

At least two COVID-19 vaccinations are preferred.

Responsibilities

Manage an assigned caseload of up to 50 members and complete up to two scheduled in-person visits per member per month.
Meet a minimum productivity standard of 100 billable encounters each month.
Serve as the primary contact for members and coordinate communication and care with healthcare providers, social services, and caregivers.
Conduct comprehensive health and psychosocial assessments and develop individualized, member-centered care plans addressing physical health, mental health, substance use disorder, and other needs.
Complete comprehensive assessments and care plans within 30 days of member enrollment.
Implement and monitor care plans, support member goal setting, provide education, and address barriers to care.
Ensure members receive all seven ECM core service components: outreach and engagement; comprehensive assessment and care management plan; enhanced coordination of care; health promotion; comprehensive transitional care; member and family supports; and coordination of and referral to community and social support services.
Provide mental health promotion, social work services, crisis intervention, and connections to community resources.
Provide responsive support, which may include weekend work, when needed to support continuity and transitional care, including following emergency room admissions.
Help members navigate health services, including arranging transportation and scheduling appointments.
Meet regularly with members’ providers to support continuity of care and keep relevant parties informed of member progress and needs.
Refer members to other providers and services as needed.
Verify each assigned member’s eligibility at the beginning of each month and mid-month.
Document services accurately and promptly in accordance with Medi-Cal and Medicare billing requirements; maintain member records in the EHR and other business systems; enter notes by the end of the business day in which services are provided; and upload required documentation in a timely manner.
Conduct self-audits every 90 days for each assigned member and assist with external audits by gathering and organizing records.
Complete monthly reporting and monitor billing procedures for compliance with funding, state, and federal requirements.
Maintain working knowledge of JI Services, including billable encounter limits and applicable billing requirements, and tailor outreach and care coordination to the needs of the JI population of focus.
Conduct and log outreach and engagement activities, explain program services, and complete intake, enrollment, and orientation for assigned members.
Provide clinical guidance in applying evidence-based practices, including Motivational Interviewing and Trauma-Informed Care principles.
Perform administrative tasks using HIPAA-compliant systems and uphold patient confidentiality.
Follow BVHPF’s Lone Worker Policy during field work, including consistent use of the assigned personal safety device during community and home visits.
Attend required training, contribute to team development, and maintain effective relationships with internal staff and external partners.
Use video conferencing tools for remote collaboration.
Provide coverage for additional members as directed by the Program Manager when a colleague is absent.
Perform other duties as assigned.