ECM Lead Care Manager

Bayview Hunters Point Foundation•San Francisco, CA

2d•Onsite

About The Position

The ECM and JI Services Lead Care Manager (LCM) is responsible for delivering comprehensive, member-centered case management to all populations of focus enrolled in the Enhanced Care Management (ECM) program at Bayview Hunters Point Foundation, including individuals with Justice-Involved (JI) Services eligibility. The LCM carries a full direct-service caseload, facilitates member access to health and social services, and works collaboratively with internal staff, healthcare providers, and community partners to improve member health and well-being. This position reports directly to the ECM and JI Services Program Manager. The ideal candidate brings direct case management experience, working knowledge of CalAIM and Medi-Cal requirements, and a genuine commitment to serving high-need and underserved communities.

Requirements

Bachelor’s degree in Nursing, Social Work, Public Health, or a closely related field.
A minimum of three to five years of direct case management experience, with 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 community-based resources relevant to the populations served.
Familiarity with the Enhanced Care Management (ECM) and Justice-Involved (JI) populations of focus, including a clear understanding of the distinction between justice-involved and justice-impacted individuals and how that distinction shapes service delivery.
Ability to navigate case management software, electronic health records (EHR) systems, and data reporting tools with accuracy and consistency.
Strong written and verbal communication skills, sound organizational practices, and the ability to engage effectively within a multidisciplinary team environment.
Demonstrated ability to work effectively and respectfully with individuals from diverse cultural, linguistic, and socioeconomic backgrounds.
Regular and reliable job attendance.
Effective verbal and written communication skills.
Proficiency in computer skills, including knowledge of Microsoft Office, Apricot 360 (EHR), internet browsers, and other business systems used by the program.
Exhibit respect and understanding of others to maintain professional relationships.
Independent judgement in evaluating options to make sound decisions.
MANDATED REPORTER STATUS: This position requires you to work with adults and children, and your profession qualifies you as “mandated reporters” of Elder abuse or neglect. Child abuse or neglect, which is found in California Penal Code Section 11164-11174.3 and Welfare and Institution Code 15610-15610.70. In addition, you are required to report suspected cases of child abuse and neglect and Elder abuse and neglect.
Able to meet required state, federal, local and BVHP standards.
Live Scan fingerprinting and TB clearance as well as any other medical vaccinations may be required.
Able to obtain jail clearance to enter in-custody facilities, required to serve justice-involved members in pre-release and in-custody settings.
At least two COVID-19 vaccinations (preferred).
As part of our commitment to maintaining a secure environment, all candidates selected for this position will be subject to a comprehensive background check clearance. This clearance is a standard part of our employment process and is conducted in accordance with applicable laws and regulations.

Nice To Haves

Master’s degree in Nursing, Social Work, Public Health, or a related field.
Active California licensure as a Registered Nurse (RN), Licensed Clinical Social Worker (LCSW), or equivalent professional licensure.
Current case management certification (CCM or ACM), or a demonstrated commitment to obtaining certification within an agreed-upon timeframe.
Community Health Worker (CHW) certificate or Medical Assistant (MA) certification, or equivalent credential demonstrating foundational knowledge in community-based health services.
Prior experience in Enhanced Care Management (ECM), CalAIM, or community-based healthcare and social services settings.
Experience serving high-need populations, including individuals living with chronic illness, behavioral health conditions, housing instability, or substance use disorders.
Bilingual capacity and lived experience that reflects the cultural and social backgrounds of the communities we serve are strongly preferred.
Working knowledge of or experience with Apricot 360, Availity, SmartSheets, or HealthTrio is a plus.

Responsibilities

Manage an assigned caseload of up to 50 members, completing up to two (2) scheduled in-person visits with each member per month.
Meet a minimum productivity standard of 100 billable encounters each month.
Serve as the primary contact for clients, coordinating care and communication with healthcare providers, social services, and caregivers.
Conduct comprehensive health and psychosocial assessments to develop individualized, member-centered care plans.
Oversee client goal setting and care plan development, ensuring plans address physical health, mental health, SUD, and other needs.
Ensure all comprehensive assessments and care plans are completed within 30 days of member enrollment, in accordance with program and regulatory timelines.
Implement and monitor member care plans, educating clients and addressing barriers to care.
Ensure each assigned member receives all seven (7) 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 connection to community resources.
Provide responsive support that may include some weekend work, such as when a member is admitted to the emergency room (ER), to support continuity of care and transitional care needs.
Assist clients in navigating health services, including arranging transportation and appointment scheduling.
Meet with each member’s providers on a regular cadence to ensure continuity of care and keep all parties informed of the member’s progress and needs.
Refer members to other providers as needed to ensure they are connected to all services available to them.
Verify eligibility for each assigned member at the beginning of every month and mid-month to confirm continued enrollment and benefit coverage.
Ensure accurate and timely documentation of all services provided in accordance with Medi-Cal and Medicare billing requirements.
Maintain up-to-date patient health records in the Electronic Health Record (EHR) and other business systems.
Ensure accurate and complete data is entered into the BVHPF internal EHR for all assigned members.
Upload all required documents and supporting documentation into the internal EHR in a timely manner.
Enter all member notes and service documentation into the EHR by the end of each business day in which services are provided.
Conduct self-audits every 90 days for each assigned member to ensure documentation accuracy and ongoing compliance with program, CalAIM, and CARF standards.
Assist with preparation for external audits, gathering and organizing member records and documentation as needed.
Complete monthly reporting to ensure program compliance with funding and regulatory requirements.
Monitor and adhere to billing procedures, ensuring alignment with state and federal regulations.
Maintain working knowledge of Justice-Involved (JI) Services, including the number of encounters that can be billed for JI services and the applicable billing requirements.
Understand the needs of the JI population of focus and tailor outreach, engagement, and care coordination to serve them effectively.
Conduct outreach and engagement activities to connect with eligible and interested members, explaining the program and service offerings, and log all activity in the EHR system.
Complete the intake process for members assigned to their caseload, ensuring timely enrollment and orientation to the program.
Provide clinical guidance in implementing evidence-based practices, such as Motivational Interviewing and Trauma-Informed Care principles.
Perform administrative tasks using HIPAA-compliant systems for remote work.
Respect patient confidentiality and uphold HIPAA compliance.
Adhere to BVHPF’s Lone Worker Policy at all times when conducting field-based work, including the consistent use of the assigned personal safety device to ensure staff safety during community and home visits.
Attend required training sessions, actively contribute to team development, and maintain strong working relationships with internal staff and external partners.
Utilize video conferencing tools frequently for remote collaboration.
Provide coverage for additional members as directed by the Program Manager when a colleague is out, to support continuity of services.
Perform other duties as assigned.