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About the Role

The ECM and JI Services Lead Care Manager (LCM) delivers comprehensive, member-centered case management to individuals enrolled in the Enhanced Care Management (ECM) program, including those with Justice-Involved (JI) Services eligibility. The LCM manages a direct-service caseload, facilitates access to health and social services, and collaborates with internal staff, healthcare providers, and community partners to enhance member health and well-being.

Responsibilities

Manage an assigned caseload of up to 50 members, completing up to two (2) scheduled in-person visits per month.
Meet a minimum productivity standard of 100 billable encounters each month.
Serve as the primary client contact, coordinating care 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, addressing physical health, mental health, SUD, and other needs.
Ensure comprehensive assessments and care plans are completed within 30 days of member enrollment.
Implement and monitor member care plans, educating clients and addressing barriers to care.
Ensure assigned members receive all seven (7) ECM core service components.
Provide mental health promotion, social work services, crisis intervention, and connection to community resources.
Provide responsive support, including potential weekend work for continuity of care and transitional needs.
Assist clients in navigating health services, including arranging transportation and appointment scheduling.
Meet with member providers regularly to ensure continuity of care and inform parties of member progress.
Refer members to other providers as needed.
Verify monthly eligibility for assigned members to confirm enrollment and benefit coverage.
Ensure accurate and timely documentation of all services 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.
Ensure accurate and complete data entry into the BVHPF internal EHR for all assigned members.
Upload all required documents and supporting documentation into the internal EHR in a timely manner.
Enter all member notes and service documentation into the EHR by the end of each business day.
Conduct self-audits every 90 days for each assigned member to ensure documentation accuracy and compliance.
Assist with preparation for external audits by gathering and organizing member records.
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.
Maintain working knowledge of Justice-Involved (JI) Services, including billable encounters and requirements.
Understand the needs of the JI population and tailor outreach, engagement, and care coordination.
Conduct outreach and engagement activities to connect with eligible members, explaining program offerings.
Complete the intake process for assigned members, ensuring timely enrollment and orientation.
Provide clinical guidance in implementing evidence-based practices like Motivational Interviewing and Trauma-Informed Care.
Perform administrative tasks using HIPAA-compliant systems for remote work.
Respect patient confidentiality and uphold HIPAA compliance.
Adhere to BVHPF’s Lone Worker Policy during field-based work, using the assigned personal safety device.
Attend required training sessions, contribute to team development, and maintain strong working relationships.
Utilize video conferencing tools frequently for remote collaboration.
Provide coverage for additional members as directed by the Program Manager during colleague absences.
Perform other duties as assigned.

Requirements

Bachelor’s degree in Nursing, Social Work, Public Health, or a closely related field.
A minimum of three to five years of direct case management experience, with demonstrated ability to manage complex caseloads and coordinate services across systems.
Working knowledge of care coordination, chronic disease management, behavioral health integration, social determinants of health, and community-based resources.
Familiarity with Enhanced Care Management (ECM) and Justice-Involved (JI) populations, including understanding the distinction between justice-involved and justice-impacted individuals.
Ability to navigate case management software, electronic health records (EHR) systems, and data reporting tools accurately.
Strong written and verbal communication skills.
Sound organizational practices.
Ability to engage effectively within a multidisciplinary team environment.
Demonstrated ability to work effectively and respectfully with individuals from diverse cultural, linguistic, and socioeconomic backgrounds.
Regular and reliable job attendance.
Proficiency in computer skills, including Microsoft Office, Apricot 360 (EHR), internet browsers, and other business systems.
Exhibit respect and understanding of others to maintain professional relationships.
Independent judgement in evaluating options to make sound decisions.
May require occasional evening and weekend work to meet deadlines or attend events.
Ability to work effectively in an open office environment surrounded by moderate noise and distractions.
Frequently required to sit; occasionally walk and stand; travel from the building to other sites.
Specific vision abilities required include close vision, distance vision, depth perception, and the ability to adjust focus.
The employee must be able to meet deadlines with time constraints.
May be asked to occasionally work irregular or extended hours.
Valid California’s Driver’s License (if duties require).
Mandated Reporter Status for Elder abuse or neglect and Child abuse or neglect.
Able to meet required state, federal, local and BVHP standards.
Live Scan fingerprinting and TB clearance as well as any other medical vaccinations may be required.
Able to obtain jail clearance to enter in-custody facilities.
At least two COVID-19 vaccinations (preferred).
Candidates will be subject to a comprehensive background check clearance.

Skills

Case management
Care coordination
Chronic disease management
Behavioral health integration
Social determinants of health
Community-based resources
Enhanced Care Management (ECM)
Justice-Involved (JI) Services
CalAIM
Medi-Cal
Case management software
Electronic Health Records (EHR)
Data reporting tools
Written communication
Verbal communication
Organizational practices
Team collaboration
Cultural competency
Linguistic competency
Socioeconomic understanding
Microsoft Office
Apricot 360
Internet browsers
Motivational Interviewing
Trauma-Informed Care
HIPAA compliance
Lone Worker Policy adherence
Video conferencing
Bilingual capacity (preferred)
Lived experience (preferred)
Apricot 360 (plus)
Availity (plus)
SmartSheets (plus)
HealthTrio (plus)

Location

San Francisco, CA 94124

Work Type

On-site
Occasional evening and weekend work
Occasional irregular or extended hours

Experience Level

3-5 years of direct case management experience

Education Level

Bachelor’s degree in Nursing, Social Work, Public Health, or a closely related field
Master’s degree in Nursing, Social Work, Public Health, or a related field (preferred)
Active California licensure as a Registered Nurse (RN), Licensed Clinical Social Worker (LCSW), or equivalent professional licensure (preferred)
Current case management certification (CCM or ACM) or commitment to obtain (preferred)
Community Health Worker (CHW) certificate or Medical Assistant (MA) certification, or equivalent credential (preferred)

About the Company

Bayview Hunters Point Foundation has been at the heart of social justice for over 50 years, providing support services for predominantly low-income people of color in the Bayview and throughout San Francisco.
Our mission is to build a community that is empowered, clean, safe, and healthy.
We are focused on multidisciplinary, community-informed support for our clients, addressing the root causes of unemployment and homelessness, and advocating for the basic human rights of food, health, economic and housing security.
BVHPF’s nearly 200 employees serve over 5,000 disadvantaged clients each year.
Programs include mental health counseling, substance abuse counseling, transitional housing, rapid rehousing, case management, and the Bayview SAFE Navigation Center.
Programs are funded through nearly 20 contracts with the City & County of San Francisco and monitored by CCSF, State, and Federal government.