ECM Lead Care Manager

$72,000 - $77,000/Yr

Bayview Hunters Point Foundation for Community Imp - San Francisco, CA

Full-time - Mid Level

San Francisco, CA

101-250 employees

About the position

The Lead Care Manager (LCM) at Bayview Hunters Point Foundation is responsible for providing comprehensive case management to clients enrolled in the Enhanced Care Management (ECM) program. The LCM facilitates access to health and social services, helping clients navigate the system to improve their overall health and well-being. This role requires collaboration within a multidisciplinary team and effective engagement with external partners and service providers.

Responsibilities

• 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.
• Implement and monitor member care plans, educating clients and addressing barriers to care.
• Provide mental health promotion, social work services, crisis intervention, and connection to community resources.
• Assist clients in navigating health services, including arranging transportation and appointment scheduling.
• 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.
• 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.
• Conduct outreach and engagement activities to connect with eligible members and log activity in the EHR system.
• 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.
• Attend training sessions, actively contribute to team development, and maintain strong relationships with internal and external partners.
• Utilize video conferencing tools frequently for remote collaboration.

Requirements

• Bachelor's degree in Nursing, Social Work, Public Health, or a related field required (Master's degree preferred).
• Minimum 3-5 years of case management experience.
• Experience in enhanced care management, healthcare, or social services is preferred.
• Licensure as a Registered Nurse (RN), Licensed Clinical Social Worker (LCSW), or other relevant licensure preferred.
• Case management certifications (CCM, ACM) are desirable.
• Strong leadership, communication, and problem-solving skills, with the ability to manage and mentor a team effectively.
• In-depth understanding of care coordination, chronic disease management, behavioral health, social determinants of health, and community resources.
• Proficiency in case management software, electronic health records (EHR), and data reporting tools.

Nice-to-haves

• Experience working with high-need populations, including those with chronic illnesses, mental health conditions, homelessness, and substance use disorders.