Case Manager II

About the Role

The Case Manager II (CM II) is a key member of the primary care interdisciplinary team, providing services for patients with complex care needs. This position conducts patient outreach, engagement, and psychosocial service assessment, assists in developing patient-centered care plans, leads the implementation of Enhanced Care Management (ECM), and coordinates service referrals and delivery. The CM II meets clients in home, clinic, or community settings as required and serves populations with multiple complex health and social services needs, often outside traditional health center settings such as home visits, hospitals, supportive housing sites, encampments, and shelters.

This position is represented by SEIU-UHW, with salaries and benefits set by a collective bargaining agreement (CBA). Employees must remain a member in good standing of SEIU-UHW as defined in the CBA.

Responsibilities

• Conduct outreach via telephone and in-person at LifeLong, community, and residential sites to patients who meet case management program eligibility criteria or are prioritized for services.
• Proactively engage with patients to build effective relationships and assess strengths and needs using standard intake, screening tools, and health and social services records review.
• Actively involve patients and caregivers in designing and delivering services, including development of care plans aligned with patients’ values and goals.
• Provide and facilitate referrals for internal and external resources, collaborating with patients to complete required applications, forms, or releases of information.
• Maintain a patient caseload in accordance with LifeLong standards for the specific population served or site requirements.
• Utilize data registries and reports to manage caseload, meet program requirements, maintain grant deliverables, and promote high-quality care.
• Provide health education and training, including harm reduction and disease risk-mitigation strategies, to empower patients to manage their health and wellness (e.g., overdose prevention, mitigating spread of communicable diseases).
• Assist patients with accessing and retaining public benefits and insurance (e.g., MediCal, SSI/SSDI, CalFresh, General Assistance) and affordable/subsidized housing.
• Communicate respectfully and routinely with patients, care team members, external partners, and identified social supports.
• Maintain knowledge of patients’ medical/behavioral health treatment plans and facilitate service utilization through resources such as accompaniment, transportation, in-home care, and reminder calls.
• Participate in team meetings to coordinate care, support patient goals, and reduce barriers to accessing services.
• Advocate on behalf of patients to meet their needs and support patients in learning self-advocacy strategies.
• Provide case management services to patients with complex acute or chronic medical or behavioral health conditions (e.g., HIV/AIDS, Hep C, congestive heart failure, severe diabetes, severe hypertension, psychosis, pregnancy, and homelessness).
• Provide general housing case management services, including document readiness, housing problem-solving, and assessments for the Coordinated Entry System.
• Assist with patient crisis intervention and de-escalation.
• Provide and document billable services to eligible populations to generate revenue for LifeLong.
• Stay current on community resources and social service supports to effectively serve the target population.
• Document patient contacts and services in required data systems (EHR, HMIS, etc.) according to LifeLong policy.
• Perform specific activities as required by the program and funder.
• Promote diversity, equity, inclusion, and belonging in support of patients and staff.
• Represent LifeLong positively in the community and advocate for underserved populations.