Enhanced Care Case Manager

East Valley Community Health Center•Pomona, CA

47d•$23 - $27

About The Position

Founded in 1970, East Valley Community Health Center is a Federally Qualified Health Center (FQHC) whose services include providing personalized, affordable, high-quality medical, dental, vision, and behavioral health care through a community-based network within the East San Gabriel Valley and Pomona Communities. Our staff practices patient-centered care by serving each patient with a personalized care plan that meets their individual needs. Our patients have access to support services that include, nutrition, health education, case management, pharmacy, lab, and x-ray at our health center locations. East Valley serves the healthcare needs of uninsured and underserved individuals and families throughout our 8 health center locations. Our mission is to provide access to excellent health care while engaging and empowering our patients, employees, and partners to improve their well-being and the health of our communities. Position Responsibilities and Functions: Act as a primary contact for clients throughout their full length of participation in the program for enhanced care management needs. Complete a comprehensive intake and assessment for new clients to help them determine their needs, eligibility, interests, and goals with monthly follow-up home visits supporting enhanced care management needs and housing retention. Conducts initial and ongoing assessment of client's health and/or support service needs. Sets the level of client need. Leads the provision and coordination of services and provides direct services for ECM participants in their assigned monthly caseload. Work with clients and their current and previous supports to develop individual care plans to help them meet initial and intermediate goals in the areas of education and employment, housing stability, positive health outcomes, permanent connections, and well-being. Provides basic and intensive individual support, based on client needs. Support may include providing interventions, internal and community services referrals, and more intensive support which may include a home visit. Operate in a supportive role within an interdisciplinary healthcare team utilizing an integrated care and treatment model. Connect clients to supportive services such as mental health, health, substance use, and employment and education resources with service providers. Collaborate with primary care providers and behavioral health providers to offer health and behavioral interventions that will maximize patient health outcomes. Provide support, empowerment, education, and targeted case management services to clients. Tracks, monitors, and actively manages assigned patient cases to ensure coordination of care, retention of patients, and ensuring a high level of utilization is maintained. Offer linkage to resources such as DPSS, Social Security, and Medi-Cal and act as a liaison for clients with those resources. Attend case conferencing meetings to coordinate services with internal and outside service providers. Educate clients about the health care system and facilities relationship building between the two and how to maintain set relationships. Document work with clients through appropriate record keeping that follows East Valley's policies and procedures complying with HIPPA standards and observing strict patient confidentiality. Link clients to needed services and facilitate access to community resources. Attend appropriate community resource meetings and training as assigned. MSW level case managers if requesting clinical hours for BBS requirements will be assigned 6-8 weekly therapy caseloads. Performs other duties as assigned by team leads, supervisors, and managers.

Requirements

Minimum of one year experience working with homeless individuals and have a social work/mental health-related bachelor's degree or Master's degree (preferred), or have a minimum of two years of experience providing direct mental health or intensive case management services, unless otherwise approved by DHS.
Have experience working with clients with mental illness, chronic health issues, and substance use disorders.
Have expertise in the following areas: chronic homelessness, outreach and engagement strategies, intensive case management services, best practice models, mental health and substance use disorder services, crisis intervention, suicide assessment and prevention, affordable housing and public benefits applications, housing and landlord/tenant rights and eviction prevention.
Knowledge of community resources in the area of residence.
Comfortable working with diverse populations including formerly incarcerated individuals, undocumented individuals, LGBT populations, and those experiencing homelessness, substance abuse, and/or mental illness.
Exceptional ability to connect and engage with people.
Good oral and written communication skills.
Detail-oriented, organized, and possess time management skills.
Able to work flexible job hours.
Willingness to work in various environments, including jail settings, street outreach, home visits, homeless encampments, and/or shelters.

Nice To Haves

Bilingual English/Spanish preferred (read, write, speak)

Responsibilities

Act as a primary contact for clients throughout their full length of participation in the program for enhanced care management needs.
Complete a comprehensive intake and assessment for new clients to help them determine their needs, eligibility, interests, and goals with monthly follow-up home visits supporting enhanced care management needs and housing retention.
Conducts initial and ongoing assessment of client's health and/or support service needs. Sets the level of client need.
Leads the provision and coordination of services and provides direct services for ECM participants in their assigned monthly caseload.
Work with clients and their current and previous supports to develop individual care plans to help them meet initial and intermediate goals in the areas of education and employment, housing stability, positive health outcomes, permanent connections, and well-being.
Provides basic and intensive individual support, based on client needs. Support may include providing interventions, internal and community services referrals, and more intensive support which may include a home visit.
Operate in a supportive role within an interdisciplinary healthcare team utilizing an integrated care and treatment model.
Connect clients to supportive services such as mental health, health, substance use, and employment and education resources with service providers.
Collaborate with primary care providers and behavioral health providers to offer health and behavioral interventions that will maximize patient health outcomes.
Provide support, empowerment, education, and targeted case management services to clients.
Tracks, monitors, and actively manages assigned patient cases to ensure coordination of care, retention of patients, and ensuring a high level of utilization is maintained.
Offer linkage to resources such as DPSS, Social Security, and Medi-Cal and act as a liaison for clients with those resources.
Attend case conferencing meetings to coordinate services with internal and outside service providers.
Educate clients about the health care system and facilities relationship building between the two and how to maintain set relationships.
Document work with clients through appropriate record keeping that follows East Valley's policies and procedures complying with HIPPA standards and observing strict patient confidentiality.
Link clients to needed services and facilitate access to community resources.
Attend appropriate community resource meetings and training as assigned.
MSW level case managers if requesting clinical hours for BBS requirements will be assigned 6-8 weekly therapy caseloads.
Performs other duties as assigned by team leads, supervisors, and managers.

Benefits

East Valley offers a competitive salary, and excellent benefits including medical, dental, vision, and defined contribution retirement plan.
You will also enjoy a work-life balance with paid time off and paid holidays throughout the year.

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