Case Manager IV

Key member of the primary care interdisciplinary team providing services for patients with complex care needs. Conducts patient outreach, engagement, psychosocial service assessment, and assists in developing patient-centered care plans. Leads implementation of Enhanced Care Management (ECM) and coordinates service referrals and delivery. Meets clients in home, clinic, or community settings as required. Provides comprehensive housing navigation support.

Responsibilities

• Outreach via telephone and in-person at LifeLong, community, and residential sites to patients who meet case management program eligibility criteria or are prioritized by LifeLong for this service.
• Proactively meet and 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 expressed goals of care.
• 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 to patients, including harm reduction and disease risk-mitigation strategies (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 utilization of services (e.g., accompaniment, transportation, in-home care, reminder calls).
• Participate in team meetings to coordinate care, support patient goals, and reduce barriers to accessing services.
• Provide case management services to patients with multiple 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 Coordinated Entry System.
• Assess patients to identify cognitive and/or behavioral health needs and provide brief interventions and short-term support using standardized tools.
• Co-facilitate patient groups.
• Provide intensive case management to a subset of the highest acuity patients in accordance with site or program standards.
• Provide specialized housing navigation services to patients matched to a housing resource through Coordinated Entry System.
• Lead crisis intervention response, de-escalation procedures, notification of local mental health departments and/or crisis response teams, and follow-up care.
• Provide and document billable services to eligible populations that result in revenue generation for LifeLong.
• Develop and maintain onboarding documentation pertinent to the Case Manager role.
• Provide training and onboarding support to new Case Managers under supervisor’s guidance.
• Provide ongoing technical assistance and subject-matter expertise through consultation and case conferencing.
• Coordinate special projects assigned by site or program leadership.
• Assist with triaging caseloads using data tools to identify patients and prioritize outreach, screenings, and follow-up activities.
• Mentor and coach Case Managers, Interns, Apprentices, and Volunteers.
• Assist in implementation of quality improvement and quality assurance efforts.
• Assist in development and implementation of new workflows pertinent to the Case Manager role.
• Advocate on behalf of patients to meet their needs and support patients in learning self-advocacy strategies.
• Keep current on community resources and social service supports to effectively serve the target population.
• Document patient contacts/services in required data systems (EHR, HMIS, etc.) according to LifeLong policy.
• Promote diversity, equity, inclusion, and belonging in support of patients and staff.
• Represent LifeLong positively in the community and advocate on behalf of underserved populations.

Qualifications

• Role in relation to other case managers includes providing case manager onboarding and training, using data for caseload management and quality assurance, and involvement in quality improvement projects.
• Position is represented by SEIU-UHW; salaries and benefits are set by a collective bargaining agreement (CBA). Employee must remain a member in good standing of SEIU-UHW as defined in the CBA.