Case Manager I

• Patient outreach and engagement, including referral/record review and direct communication with patient regarding Enhanced Care Management program eligibility and services
• Determine patients' eligibility and requirements by supporting the completion of a comprehensive intake assessment
• Support the development of a Care Management Plan (CMP) that incorporates patient's needs in the areas of physical health, mental health, SUD, community-based Long Term Services Support, oral health, palliative care, social supports, and Social Determinants of Health. Engage and help patient participate in and manage their care
• Support as part the ECM team patient's care coordination and organizing patient's care activities per the CMP
• Share and maintain information with patient's multidisciplinary team and implementing activities per CMP, including Community Supports. Communicate patients' progress by participating in interdisciplinary meetings and evaluations; disseminating results and obstacles to therapeutic team and patient family; identifying treatment influences
• Develop, establish, and maintain professional and collaborative working relationships with internal and external care team
• Support patient engagement in treatment including coordination or medication review and/or reconciliation, scheduling appointments, appointment reminders, coordinating transportation, accompany patient to critical appointments, identify and address other barriers to patient's engagement in treatment
• Identify need for and coordinate access to education and training in priority clinical knowledge areas in linkage to primary care; integration of SUD care and chronic pain management; management of chronic medical and behavioral conditions; preventive care; etc.
• Ensure regular contact with the patient and their family member(s), guardian, caregiver, and/or authorized support person(s) as part of care coordination
• Support patient in strengthening their skills to identify and access resources to assist them in managing and prevention of chronic condition
• Effectively manage crisis by using Motivational Interviewing and De-escalation skills, both in support of the patient and other team members
• Support lead case manager with providing transitional care for patients during discharge from hospital or institutional setting including developing a transition care plan, and coordination of care to provide adherence support and referrals to appropriate resources and community supports, as needed.
• Assist patient in accessing additional benefits and related documentation such as, Social Security Insurance (SSI), CalFresh, cash aid, and obtaining required documentation to apply (ID, birth certificate, immigration status, financial records, marriage/divorce records, proof of medical conditions, etc. Facilitates referrals to Community Health Services when appropriate.
• Offer exceptional care coordination skills that include warm hand-offs and closed-loop referrals
• Maintains up to date, within 24 hours of service delivery, adequate records and other documentation necessary for the collection of data and statistics pertaining to program outcomes, demographics, and information as required by funders
• Support Lead Case Manager by utilizes on-going assessment skills to ensure high quality of treatment and care
• Maintains professional competence by pursuing opportunities for continuous learning, continuing education offerings, reading professional literature, and engaging in other activities, which develop new knowledge and skills.
• Collaborates with Enhanced Care Management Team to build the new program workflows; implement changes; policies and procedures as appropriate in conjunction with Director of Behavioral Health and Case Management.
• Maintains current patient records by reviewing case notes; logging events and progress effectively and efficiently in the electronic health record (EHR). Monitors patient's treatment compliance and referral outcomes.

• A bachelor's degree in social work, psychology or related field from an accredited college/university and at least six (6) months experience providing mental health services, including intensive case management or health care coordination; OR
• Associate's degree and three (3) years' experience of direct services in mental health, community services, health care coordination, and/or case management, OR
• High School Graduate or G.E.D. equivalent and four (4) years of direct services in mental health, community services, health care coordination, and/or case management
• Understanding of community resources and ability to easily build rapport and maintain engagement with patients served.
• Strong computer skills, including able to easily navigate around health care systems
• General understanding of the complex needs of families in our community
• Ability to assess safety risks
• Bilingual in Spanish required, Bi-cultural preferred
• Knowledge of basic medical and psychiatric terminology
• Must have valid CA driver's license and clean driving record
• Ability to move between sites and perform duties in the field in a variety of settings
• Knowledge of or reasonable ability to learn use of Electronic Health Record
• Willingness to work a variable schedule, which may include evenings and Saturdays.

• Sitting, typing, reaching, bending, moving and/or lifting up to 25 pounds.

Salud Para La Gente