Case Manager IV

• Outreach, via telephone and in person at LifeLong, community and residential sites, to patients who meet case management program eligibility criteria or are prioritized by LifeLong for this service
• Proactively meet and engage with patients to build effective relationships and assess strengths and needs through use of standard intake, screening tools, and health, and social services records review
• Actively involve patients and caregivers, as appropriate, in designing and delivering services, including development of care plans, assuring alignment with patients’ values and expressed goals of care
• Provide and facilitate referrals for internal and external resources, and collaborate with the patient to complete required applications, forms, or releases of information
• Maintain a patient caseload in accordance with LifeLong standards for the specific population served or site requirements
• Utilize data registries and reports to manage caseload, meet program requirements, maintain grant deliverables, and promote high quality care
• Provide health education and training to patients, including but not limited to, harm reduction and disease risk-mitigation strategies that empower patients to manage their own health and wellness (e.g. overdose prevention, mitigating spread of communicable diseases)
• Assist patients with accessing and retaining public benefits and insurance (e.g. MediCal, SSI/SSDI, CalFresh, General Assistance), and affordable/subsidized housing
• Respectfully and routinely communicate with patients, their care team members, external partners, and identified social supports
• Maintain knowledge of patients’ medical/behavioral health treatment plans and facilitate utilization of services by providing resources such as accompaniment, transportation, in-home care, reminder calls etc.
• Participate in team meetings to coordinate care, support patient goals, and reducing barriers to accessing services
• Provide case management services to patients with multiple complex acute or chronic medical or behavioral health conditions (e.g. HIV/AIDS, Hep C, congestive heart failure, severe diabetes, severe hypertension, psychosis, pregnancy, and homelessness)
• Provide general housing case management services that includes document readiness, housing problem solving, and assessments for Coordinated Entry System
• Assess patients to identify cognitive and/or behavioral health needs and provide brief interventions and short-term support using standardized tools and effective approaches for patient care
• Co-facilitate patient groups
• Provide intensive case management to a caseload size in accordance with site or program standards focusing on a subset of the highest acuity patients
• Provide specialized housing navigation services to patients who are matched to a housing resource through Coordinated Entry System
• Lead crisis intervention response, de-escalation procedures, notification of the local mental health department and/or crisis response team, and follow-up care
• Provide and document billable services to eligible populations that result in revenue generation for LifeLong
• Develop and maintain onboarding documentation pertinent to the Case Manager role
• Provide training and onboarding support to new Case Managers according to program policy and procedure and under supervisor’s guidance and oversight
• Provide ongoing technical assistance and subject matter expertise through consultation and case conferencing
• Coordinate special projects assigned by site or program Leadership
• Assist with triaging caseloads using data tools to identify patients and prioritize outreach, screenings, and follow up activities
• Mentor and coach Case Managers, Interns, Apprentices, and Volunteers
• Assist in implementation of quality improvement and quality assurance efforts
• Assist in development and implementation of new workflows pertinent to the Case Manager role
• The CM IV is not a management position and is not responsible for supervisorial tasks
• Advocate on behalf of patients to get their needs met and/or support patients to learn advocacy strategies for themselves.
• Keep current on community resources and social service supports to effectively serve the target population
• Document patient contacts/services in required data systems (EHR, HMIS etc.) according to LifeLong policy
• Specific activities may vary depending on the requirements of the program and funder.
• Promote diversity, equity, inclusion, and belonging in support of patients and staff
• Represent LifeLong positively in the community and advocate on behalf of underserved populations

• Commitment to working directly with low-income persons from diverse backgrounds in a culturally responsive manner
• Commitment to harm reduction, recovery, housing first, age-friendly and patient centered care
• Strong organizational, administrative and problem-solving skills, and ability to be flexible and adaptive to change while maintaining a positive attitude
• Excellent interpersonal, verbal, and written skills
• Ability to prioritize tasks, work under pressure, and complete assignments in a timely manner
• Ability to seek direction/approval on essential matters, yet work independently, using professional judgment and diplomacy
• Works well in a team-oriented environment
• Conducts oneself in external settings in a way that reflects positively on your employer
• Ability to be creative, mature, proactive, and committed to continual learning and improvement in professional settings

• High School diploma or GED
• At least three (3) years of progressively responsible work or volunteer experience in a community-based health care or social work setting or at least one (1) year of experience as either a Case Manager II or Case Manager III or equivalent position and registration or certification as a Certified Alcohol and Drug Counselor by one of the two certifying bodies in California
• Proficient skills using Microsoft Office applications like Word, Excel, and Outlook, as well as the ability to work in and/or manage databases
• Access to reliable transportation with current license and insurance
• Manage and analyze data for patient management and quality improvement
• Strong track record of meeting program requirements including productivity and documentation timeliness
• Experience training, coaching and mentoring
• Project management experience
• Strong problem-solving skills

• Bachelor’s Degree in Social Work, Health or Human Services field
• Lived experience of homelessness, incarceration, foster care, mental health services, substance use services or addiction, or as a close family member of someone who has this experience

LifeLong Medical Care