ECM, SF - Care Manager

JOB SUMMARY HealthRIGHT 360, a nonprofit organization and a family of programs, is committed to providing accessible and comprehensive healthcare services to vulnerable populations. Our mission is to tackle systemic barriers to healthcare and promote health equity for all. We offer a wide range of services, including mental health care, residential and outpatient substance use treatment, and primary health services. Additionally, we provide transitional support for individuals re-entering the community after involvement in the criminal justice system. By integrating physical and behavioral health, we empower individuals to overcome challenges by addressing social determinants of health, fostering resilience, and facilitating recovery. The HealthRIGHT 360 ECM program is based in the Integrated Care Center Clinic, a federally qualified health center that provides primary care, behavioral health, addiction treatment, psychiatry, dental care, and more. We provide care to those most in need including those who are suffering from homelessness, mental illness, substance use, mental illness, and chronic medical conditions. We provide team-based care in an integrated care setting. We are looking for a mission driven service leader who works well in a team, has experience with managing and supporting members, champions quality improvement, leads change, and is excited to innovate. The Care Manager will provide intensive, client-centered case management to support both patients in the ICC and across other HealthRIGHT 360 programs in San Francisco, in achieving stability, health, and self-sufficiency.  The Case Manager I, under the Enhanced Care Management (ECM) program, is responsible for maintaining a caseload of members enrolled in a Managed Care Plan (MCP). This role focuses on delivering community-based case management services, linking clients to appropriate resources to address needs such as health benefits, physical and behavioral health care, substance use treatment, housing, employment, justice-involved issues, family services, and other social supports. In partnership with the San Francisco Health Plan and HealthRIGHT 360’s Integrated Care Clinic (ICC)—a brick-and-mortar primary care site located at 1563 Mission Street in San Francisco—the Care Manager I provides coordinated care to a diverse patient population. This includes collaboration with clinical and community providers to ensure comprehensive service delivery. This is a field-based position requiring proactive outreach and engagement with members in the community, including visits to clients' homes, service provider sites, and other locations across San Francisco. KEY RESPONSIBILITIES Client Care and Care Coordination Responsibilities: The Care Manager will be responsible for organizing patient care activities, sharing information with those involved as part of the multi-disciplinary care team, and implementing activities identified in the Managed Care Plan. Identifying eligible people from within State Prisons, County Jails, hospitals, and other locations for enrollment into ECM. Using multiple strategies for engagement, including direct communication with the member (and/or their advocates), such as in-person meetings where the member lives, seeking care or is accessible; mail, email, texts, and telephone; community and street-level outreach. Maintaining regular contact with all providers identified as part of the members’ care team, whose input is necessary for successful implementation of member goals and needs, including Justice Involved oversight. Ensuring care is continuous and integrated among all service providers and referring to and following up with primary care, physical and developmental health, mental health, SUD treatment, and necessary community-based and social services, including housing, as needed. Providing support to engage the member in their treatment, including coordination for medication review and/or reconciliation, scheduling appointments, providing appointment reminders, coordinating transportation, accompaniment to critical appointments, and identifying and helping to address other barriers to member engagement in treatment. Responsible for engaging with a multi- disciplinary care team to identify gaps in the member’s care and ensure appropriate input is obtained to effectively coordinate all primary, behavioral, developmental, oral health, Community Supports. Assist the client with intake by completing assessments as required by the MCP. Monitors client's progress toward achieving Care management treatment plan goals and provides treatment plan input. Assess the client’s Care Manager needs and completes all Releases of information. Connects the client to benefits, healthcare services, employment, housing, community resources, outpatient substance use services, and other benefits/resources available to the client. Coordinates communication and external service linkage including assisting with scheduling appointments, communicating with probation, scheduling child visits, communicating with Family and Children Services, obtaining all court minute orders, providing appointment reminders for therapy and psychiatrists. Collaborate with clients and their families to support reintegration into the community. Collaborate with outside agencies to help clients obtain needed community resources (housing, sober livings, substance abuse recovery agencies, medical facilities, employment/education agencies, DPSS, DMV or other needed resources). Clinical Documentation and Administrative Responsibilities: Write and complete all progress notes within 24 hours of service delivery. Write clients’ progress letters and court reports. Complete all assigned Peer Reviews (Chart Audits) within a timely matter. Actively participate in assigned Group Supervision, agency, and team meetings. Participate in training opportunities and complete assigned training in a timely manner. Training, Supervision and Quality Improvement Responsibilities: Attend and actively participate in assigned case conferences to advocate a collaborative discussion for treatment needs. Actively participate in agency and team meetings. Participate in training opportunities. Communicates collaboratively with all members of the behavioral health team including medical, mental health, psychiatry, substance use disorder, and other staff. Complete all assigned training and Relias course assignments in a timely manner. Field-Based Responsibilities This is a field-based position which requires frequent travel. A major component of the Care Manager role involves meeting ECM members where they are in terms of their physical location and individual needs. The locations for client engagement and case management will be those most attainable and desirable for clients to receive services pertaining to their medical management, including substance use disorder, and plan of care. In addition, the Case Manager will have access to an office space for case management activities, clinical supervision, and to attend all required training and meetings as needed. And perform other duties as assigned. QUALIFICATIONS Education, Certification, or Licensure High school diploma or equivalent required. A minimum of two years’ experience in case management. Demonstrated expertise in substance use treatment, relapse prevention, and recovery preferred. Current First Aid and CPR certification. Valid California driver’s license and access to registered and insured transportation. Experience working with clients experiencing acute withdrawal from substances. Experience delivering evidence-based practices preferred. Experience providing trauma-informed services preferred. Experience working with clients experiencing acute withdrawal from substances. Knowledge and Skills Professionalism, punctuality, flexibility and reliability are imperative. Knowledge of and experience with providing trauma-informed services. Strong computer skills, including Outlook, Excel, Word and PowerPoint. Integrity to handle sensitive information in a confidential manner. Strong problem-solving skills. Outstanding ability to follow through with tasks. Ability to work cooperatively and effectively as part of an interdisciplinary team and independently assume responsibility. Able to communicate well at all levels of the organization including working with organization leadership and high-level representatives of partner organizations. Able to work within a frequently changing project scope while maintaining overall direction and structured priorities. PHYSICAL REQUIREMENTS In an 8-hr workday, employee is required to perform work: Sitting 4 Hrs Standing 2 Hrs Walking 2 Hrs Driving Frequently In an average month, employee must travel out of town: ☐ Often (>2x) ☒ Sometimes (<2x) ☐ Never In an 8-hr workday, employee must: Not at all Occasionally (1/4-2½ hrs.) Frequently (2½-5½ hrs.) Continuously (5½-8 hrs.) Bend/stoop ☐ ☒ ☐ ☐ Climb ☒ ☐ ☐ ☐ Reach above shoulder level ☐ ☒ ☐ ☐ Kneel ☐ ☒ ☐ ☐ Balance ☐ ☒ ☐ ☐ Push/pull ☐ ☒ ☐ ☐ Squat ☐ ☒ ☐ ☐ Crawl ☐ ☒ ☐ ☐ Crouch ☐ ☒ ☐ ☐ Lift* ☐ ☒ ☐ ☐ Carry** ☐ ☒ ☐ ☐ * Usual number Maximum number 5 20 lbs lbs ** Usual number Maximum number 5 20 lbs lbs Job requires: Working at heights ☐ Yes ☒ No Explain Operating heavy machinery ☐ Yes ☒ No Type Operating desk machines ☒ Yes ☐ No Type Computer, fax, printer, phone Precise manual dexterity ☒ Yes ☐ No Explain Data entry, documentation Exposure to extreme heat, cold, humidity ☐ Yes ☒ No Explain Exposure to dust, fumes, gases, chemicals ☐ Yes ☒ No Explain