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About the Role

The ECM and JI Services Lead Care Manager (LVN) delivers member-centered case management for the Enhanced Care Management (ECM) program, including Justice-Involved (JI) Services. This role involves managing a caseload, facilitating access to health and social services, and collaborating with various stakeholders 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 with each member per month.
Meet a minimum productivity standard of 100 billable encounters each month.
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.
Ensure all comprehensive assessments and care plans are completed within 30 days of member enrollment, in accordance with program and regulatory timelines.
Implement and monitor member care plans, educating clients and addressing barriers to care.
Ensure each assigned member receives all seven (7) ECM core service components.
Provide mental health promotion, social work services, crisis intervention, and connection to community resources.
Provide responsive support that may include some weekend work for continuity of care and transitional care needs.
Assist clients in navigating health services, including arranging transportation and appointment scheduling.
Meet with each member’s providers on a regular cadence to ensure continuity of care and keep all parties informed of the member’s progress and needs.
Refer members to other providers as needed to ensure they are connected to all services available to them.
Verify eligibility for each assigned member at the beginning of every month and mid-month to confirm continued enrollment and benefit coverage.
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.
Ensure accurate and complete data is entered 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 in which services are provided.
Conduct self-audits every 90 days for each assigned member to ensure documentation accuracy and ongoing compliance with program, CalAIM, and CARF standards.
Assist with preparation for external audits, gathering and organizing member records and documentation as needed.
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 of focus and tailor outreach, engagement, and care coordination to serve them effectively.
Conduct outreach and engagement activities to connect with eligible and interested members, explaining the program and service offerings, and log all activity in the EHR system.
Complete the intake process for members assigned to their caseload, ensuring timely enrollment and orientation to the program.
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.
Adhere to BVHPF’s Lone Worker Policy at all times when conducting field-based work.
Attend required training sessions, actively contribute to team development, and maintain strong working relationships with internal staff and external partners.
Utilize video conferencing tools frequently for remote collaboration.
Provide coverage for additional members as directed by the Program Manager when a colleague is out, to support continuity of services.
Perform other duties as assigned.

Requirements

Must possess a current State of California LVN license in good standing, with required professional liability insurance.
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 relevant to the populations served.
Familiarity with the Enhanced Care Management (ECM) and Justice-Involved (JI) populations of focus, including a clear understanding of the distinction between justice-involved and justice-impacted individuals and how that distinction shapes service delivery.
Ability to navigate case management software, electronic health records (EHR) systems, and data reporting tools with accuracy and consistency.
Strong written and verbal communication skills, sound organizational practices, and the 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.
Ability to work effectively with diverse, underserved, immigrants and minority communities.
Demonstrated flexibility, initiative, and ability to function as a proactive team member.
Ability to work independently, while also seeking supervision and guidance when appropriate.
Strong organizational skills, including the ability to prioritize, multitask, and meet deadlines.
Dependable, adaptable, and able to work effectively under pressure; receptive to change and cooperative in problem-solving situations.
Regular and reliable job attendance.
Effective verbal and written communication skills.
Proficiency in computer skills, including knowledge of Microsoft Office, Avatar, internet browsers, etc.
Exhibit respect and understanding of others to maintain professional relationships.
Independent judgement in evaluation options to make sound decisions.
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 by this job 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 while performing job duties.
Valid California’s Driver’s License (if duties require).
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.
At least two COVID-19 vaccinations (preferred).
Candidates selected for this position will be subject to a comprehensive background check clearance.

Skills

Case management
CalAIM
Medi-Cal
Care coordination
Chronic disease management
Behavioral health integration
Social determinants of health
Community-based resources
Enhanced Care Management (ECM)
Justice-Involved (JI) Services
Case management software
Electronic health records (EHR)
Data reporting tools
Written communication
Verbal communication
Organizational practices
Team collaboration
Cultural competency
Working with diverse communities
Flexibility
Initiative
Proactive teamwork
Independent work
Prioritization
Multitasking
Meeting deadlines
Adaptability
Problem-solving
Microsoft Office
Avatar
Internet browsers
Judgment
Decision-making
Motivational Interviewing
Trauma-Informed Care principles
HIPAA compliance
Lone Worker Policy adherence
Video conferencing

Location

San Francisco, CA 94124

Work Type

Onsite
Field-Based

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
LVN license

About the Company

Bayview Hunters Point Foundation is a welcoming space for all, regardless of race, gender, sexuality, country of origin, religion, or ability.

Equal Opportunity

Candidates from a diversity of backgrounds are strongly encouraged to apply.
Bayview Hunters Point Foundation is an Equal Employment Opportunity Employer.