The Lead Care Manager is a part of a multidisciplinary team and is responsible for coordination of all aspects of Enhanced Care Management (ECM). The Lead Care Manager oversees the provision of ECM services and implementation of the care plan, conducts outreach to assigned ECM members, engages them in enrolling into ECM, and delivers ECM services. Enhanced Care Management services are provided where the member lives, seeks care, in the office, and in the community.
The Lead Care Manager (LCM) will serve on a multi-disciplinary team and is responsible for coordination of all aspects of Enhanced Care Management (ECM). The position is responsible for engaging with people and their families in the community who need services. The LCM will assist in identifying available services, including formal and informal supports and services available to meet their needs. The LCM will also be responsible to develop relationships in the community with community-based organizations, landlords and property managers in order to develop a support network for clients seeking services.
DISTINGUISHING CHARACTERISTICS
Lead Care Managers in this class are expected to perform complex technical work, operate at a high level of independence, and are expected to work with minimal supervision. LCM may also be involved in street outreach and may be in contact with individuals and families in crisis who may be experiencing health issues, homelessness, using alcohol and drugs, and who may not be attentive to basic personal hygiene, health, and safety practices. Incumbents may experience a number of unpleasant sensory demands associated with the client’s use of alcohol and drugs, and lack of personal hygiene. LCM must be ready to respond quickly and effectively to many types of situations, including crisis situations and potentially hostile situations. LCM may also be required to work flexible hours.
SUPERVISION RECEIVED AND EXERCISED
General direction is provided by a Program Director/Supervisor or higher-level management position within the department.
Typical Duties
Work in cooperation as part of a multi-disciplinary team with representatives from programs in social services agencies, community partners, community members, landlords, and other governmental agencies to identify services to meet the client’s needs.
Demonstrate flexibility, enthusiasm, and willingness to cooperate while working with others in multi-disciplinary teams.
Establish and maintain positive, productive working relationships with clients, client’s families, caregivers, and client’s care team.
Interview and screen new and established patients to determine eligibility for health insurance and other programs, including Medi-Cal, Covered California, CalFresh, CalWORKs, and General Assistance.
Assist clients and community members with completing and submitting applications through Covered California, other benefit applications, or paperwork associated with services.
Meet with clients in their homes, physician offices, Serenity Health Services, community members’ offices, street outreach, or other agreed upon public places to introduce programs, perform intake assessments, risk assessments and get appropriate consents.
Complete assessment to determine client needs and identify resources available to meet those needs.
Collect Vital Documents (State ID, Birth Certificate, Social Security Card) and upload documents in various benefit applications as needed.
Assist clients and service providers in collecting Verification of Disability Status or Med-9, signed by a licensed professional.
Work with referring agency staff to coordinate initial client meetings and discuss program expectations.
Manage a caseload involving the determination of the most complex initial and continuing eligibility criteria for more than one services in the following areas of, but not limited to: independent living skills, housing stabilization, money management, community integration, employment linkage, benefits establishment, linkage to community providers for substance abuse, primary and mental health care, health care, and all other services needed to assist clients in reaching their treatment plan goals
Develop an individualized treatment plan in collaboration with clients addressing short term and long-term goals.
Communicate with and provide feedback to referral sources, including physicians, advanced practice providers, behavioral health specialists, social services, employees, and care coordinators as appropriate.
Follow-up with clients they have engaged with to ensure that they have connected with support structures and received the services they need.
Provide on-going case management support to assess progress and ensure treatment plan outcomes are met or changed as needed.
Conduct crisis and risk assessments in consultation with a supervisor or multi-disciplinary team.
Provide crisis intervention services focused on enhancing the client’s ability to independently problem solve, utilize effective coping skills, and manage and self-coordinate their own care.
Facilitate access to services required to foster housing readiness (credit repair, legal aid, housekeeping, money management, tenant rights, and responsibilities, etc.) as needed.
Provide information and instruction to clients regarding how to complete paperwork needed to obtain services.
Act as the primary contact point, advocate, and source of information for clients, employees, or community members who provide assistance or care to the client.
Serve as mediator or advocate for the client with service providers, as needed.
Promote awareness of social determinant health issues and the commitment to recovery, wellness, and self-help.
Conduct community outreach to raise awareness and link individuals to available health, behavioral health, and social services programs.
Collect monthly updates from agencies on referrals sent.
Maintain complete client records, daily activity logs, mileage logs, and other reports as directed.
Collect and record program data into various software programs.
Responsible for tracking and reporting all required data for enrollment and outreach efforts.
Attend staff meetings, case conferences, training workshops, and community meetings as needed.
Coordinate primary, behavioral, developmental, oral health, and Community Support services that address social determinants of health needs.
Primary liaison to support primary care needs with appropriate primary care service provider and other community services
Accompany member to office visits, as needed including providing transportation
Essential job duties may be assigned that are not listed above but are relative to this job classification. (Reasonable accommodation will be made when requested and determined by Serenity Health Services to be appropriate under applicable law.)
Minimum Qualifications
MINIMUM QUALIFICATIONS
Minimum qualifications are used as a guide for establishing the education, training, experience, special skills, and/or license which are required and equivalent to the following.
Knowledge of:
● Knowledge of data collection practices and reporting skills.
● Knowledge of interviewing techniques.
● Basic understanding of mental health, physical health, and substance abuse issues and symptoms.
● Current knowledge of social work practices and principles related to best practice standards.
● Knowledge of social services programs related to homeless and housing, behavioral health, public health services, intellectual and developmental disabilities, birth equity, and justice-involved.
Skill/Ability to:
Work and communicate effectively with people with diverse backgrounds by respecting beliefs, interpersonal styles, attitudes, and behaviors of both clients and co-workers
○ Communicate and relate effectively with clients, who may be emotionally or mentally disabled, medically disabled, elderly, substance abusers, and victims of domestic violence or fiduciary abuse.
○ Establish and maintain effective working relationships with others, including clients, family members, and others who may be under distress or duress.
○ Operate contemporary office equipment inclusive of a computer, keyboard, and all applicable electronic equipment.
● Ability to listen with sensitivity to other people’s feelings, needs, and point of view; demonstrate tact and courtesy in expressing opinions or ideas, and to recognize opportunities to enhance community relations.
● Ability to work in a typical office environment and in areas inhabited by homeless persons, including working in dirty environments and dealing with challenging individuals.
● Be able to work flexible hours.
● Excellent organization skills and detail-oriented; ability to manage multiple cases efficiently and effectively.
● Creative problem-solving skills.
● Ability to maintain a calm and sensitive demeanor in stressful situations.
● Exercise exceptional interpersonal skills, good judgment, and an understanding of highly complex and political environments.
● Demonstrate strong analytical skills, excellent communication, and presentation skills.
● Ability to build and maintain good working relationships with landlords and other community partners.
● Adjust to changes in workload, coordinate work with others and work under stress of meeting deadlines.
● Maintain confidentiality of all materials and patient/client information.
● Attend meetings outside of regular working hours.
Education:
● Two (2) years of college courses in the Mental Health, Human Services, Social Work, Biological, Social Sciences field or related field.
Equivalency for Education:
● Direct program experience working with public health programs, social services program, or behavioral health program may be substituted for the educational requirement on a ratio of one (1) year of direct experience for one (1) year of college education
Experience:
● One (1) year of experience working in a social services program, public health program, or behavioral health program.
LICENSE OR CERTIFICATE
Possession of, or ability to obtain, an appropriate, valid California driver's license.
DESIRABLE EMPLOYMENT STANDARDS
Bilingual (Spanish)
Supplemental Information
Introductory Period: Six (6) Months
FLSA: Non-exempt
$25 - $30 per hour