ECM Case Manager & Intake Coordinator

San Francisco Community Health Center•San Francisco, CA

2d•$31 - $33•Hybrid

About The Position

San Francisco Community Health Center is a Federally Qualified Health Center (FQHC) that provides culturally competent high quality medical care, mental health services, education, and outreach. We are a safety-net for vulnerable populations including unsheltered community, people who use substances, immigrants, and those with mental health needs. We are an anchor-organization for San Francisco’s Tenderloin neighborhood, and we also lead regional, statewide, and national programming.  We believe that everyone deserves access to the highest quality care and are treated with dignity and respect.  The Taimon Booton Navigation Center (TBNC) is our shelter and service center for transgender, gender non-conforming & intersex people, as well as cisgender women, to find sanctuary, community, and a pathway to housing. TBNC's gender-supportive facility offers refuge, belonging, and safety and is the only shelter in Northern California attached to a Federally Qualified Health Center (FQHC). It is our hope that everyone who stays at TBNC leaves feeling safer, more supported, and on their way to stable housing. The Intake Coordinator is the first person our guests will meet upon entry to the Navigation Center. They are responsible for creating a welcoming and safe environment. This role will oversee and optimize the intake process, screen guests for Medi-Cal eligibility, enhance client support, and strengthen the center’s ability to serve the target population effectively. The Intake Coordinator position includes screening new TBNC guests for Enhanced Care Management (ECM) eligibility and working with SFCHC staff to refer those patients into the TBNC ECM program. The position of Case Manager II is primarily focused on the Enhanced Care Management program (ECM). ECM is an intensive case management benefit provided to eligible Medi-Cal members. ECM work focuses on addressing a client’s barriers to health and wellness, including connection to primary care, housing stability, food security, behavioral health treatment and any other needed community benefits. The ECM case manager will engage with prospective ECM clients and describe the benefit to participants. These individuals are identified and referred by members of their care team, including TBNC shelter staff, Behavioral Health staff members, or Primary Care Providers. The fundamental tasks include conducting a field-based assessment of clients’ needs, developing patient-centered care plans and working with the patient and multidisciplinary care team to enact goals identified within that plan. The ECM case manager serves as an integral member of the TBNC team to provide wrap-around services for guests in a team-based model.

Requirements

BA in a health sciences or social work-related field or AAA/CMH/CHW OR comparable work experience
Must be able to sit, stand, and walk for extended periods of time around the Tenderloin area, SOMA districts other San Francisco neighborhoods. This position will have Case Manager in the field more than 50% of the time.
At least one year of experience providing counseling, advocacy, education and service coordination and/or outreach work to disenfranchised communities
Knowledge and expertise how to navigate resources in San Francisco to support the target population related vulnerable populations.
Knowledge of HIV/AIDS, STIs, substance use, mental health, social service probation system
Knowledge of harm reduction philosophy, client centered counseling, and motivational interviewing techniques and trauma informed care.
Experience working with diverse sexual/gender orientations, the homeless, limited English speakers, and/or multiple-diagnosed individuals
Demonstrated excellence in attendance and reliability, interpersonal, organizational, verbal, and written communication skills, proficiency in English
Familiarity and experience with Microsoft Word and Outlook programs
Detail-oriented with strong follow-through skills, including attention to and respect for detail
Must be adaptive, flexible and a team player
Up-to-date with vaccinations, especially the latest COVID-19 and flu vaccines and able to show proof of vaccination.

Nice To Haves

Bicultural, bilingual in Spanish (or other SF Threshold Language)
Experience working in a Federally Qualified Health Center or another type of Community Health Center.
Self-starter and self-motivated
PC computer skills preferred, especially with MS Office products
Experience in providing social services or refugee assistance
Knowledge of EPIC, Excel, Zoom and being able to learn other computer programs related to administrative work.

Responsibilities

Conduct TBNC intakes, provide assessments to new clients, provide care plans and supportive meetings to complete the goals and tasks on the care plan.
Screen TBNC guests for Medi-Cal and ECM eligibility on intake.
Work with ECM and TBNC leadership at SFCHC to make ECM referrals as appropriate.
Connect guests with eligibility support if a patient does not have adequate insurance on intake.
Provide supportive counseling and develop service goals with clients.
Provide information and referrals to external services and monitor referral completion.
Participate in case conferences, morning huddles, monthly staff meetings, and in-service training.
Participate and comply with agency quality assurance, peer review, and clinical consultation.
Navigate and outreach clients as needed.
Make sure rosters/waitlists are up to date daily.
Distribute all relevant and updated materials to the site.
Keep all documents, IDs, ROIsetc. up to date in ONE and in the files.
Serve as a Lead Care Manager on the interdisciplinary Enhanced Care Management (ECM)TBNC team to provide wrap-around services/care for clients in a team-based model.
Adhere to all policies and procedures for the ECM care delivery model, including outreach, assessments, care plans, and other related duties.
Provide leadership within a client’s multidisciplinary care team to ensure progress towards achieving a client’s care goals.
Work with clients in their lived environment to address the social determinants of health impacting a client’s health and wellness.
Monitor acute changes in client status to revisit care plans accordingly and develop transitional care plans if client is seen in an acute care setting.
Work with clinical collaborators at local hospitals and community partners to connect unhoused people with a primary care team and develop client-centered care plans for clients engaged in the program.
If a client is already connected to primary care, collaborate closely with that care team to ensure a client meets their health goals.
Document appropriately in the One System and electronic medical record(Epic).
Use multiple electronic data sources to gather client and track ED or inpatient utilization care systems.
Provide culturally and racially competent client care in a manner that is both non-discriminatory and non-judgmental.
Communicate effectively with clients, other at large and departmental staff in a non-discriminatory manner.
Perform other duties as needed.