Are you ready to make an impact on the San Francisco community in a mission-critical, member facing role and help create systemic change?
The Care Management Community Coordinator (CMCC) will conduct in-person bio psychosocial assessments, create person-focused holistic care plans, and will function as a liaison, coordinating services among multiple providers and community agencies. This position will be based within the SFHP office but will involve substantial time in the community (at clinics and hospitals, with community-based organizations, and home visits). The CMCC will be responsible for managing members in the Health Homes program, a community-based program for a small subset of Medi-Cal members with complex psychosocial needs and high utilization of acute health services who require coordination at the highest levels. This will require attention to detail and the ability to adhere to workflows and documentation standards. The CMCC is expected to function independently in the field using mobile technology for regular communication with the team and should be comfortable with online clinical documentation.
This is a limited term employee position that will run through 2020.
WHAT YOU WILL DO
- Conduct initial telephone or in-person assessments for members referred for care coordination services or case management, assessing medical history, psychosocial issues, resource needs, and level of function.
- Develop member-centered, individualized Care Plans. Support the Care Management team with implementation of members’ Care Plans:
- Support members in identification of their own strengths and barriers to help them be successful with their Care Plans; respect members’ health choices in the care planning process
- Track access barriers and potential quality concerns, assisting members with grievances and escalating review in coordination with program leadership
- Partner with member in navigating the system of providers and social service agencies
- Support members and caregivers in re-assessment and modification of Care Plan goals
- Help connect members to cultural, community, housing and social resources
- Complete home visits, transport and accompany members to medical appointments, and outreach to members in the community including SROs, shelters and homeless encampments
- Actively participate in SFHP meetings and trainings as needed
- In conjunction with the CM nurse, support and educate individuals in: chronic condition management; medication management and adherence.
- Provide referrals to mental health care; substance use management and treatment; transportation services and other health needs
- Guide members through housing options; complete housing applications and provide advocacy for long term permanent housing for our homeless members
- Initiate and participate in care conferences, ensuring the member’s entire care teams participation
- Coordinate care management activities with the assigned nurse and pharmacy staff, asking for input and consultation as needed
- Coordinate with the nurse to complete the member’s medical assessments and integrate the medical care plan goals
- Complete all required documentation in a timely fashion in accordance with regulations, program standards and workflows
- Maintain privacy and confidentiality practices in accordance with regulations and program standards
- Act as a liaison to hospitals, long-term care settings, outpatient providers, home health representatives, and other community agencies
- Attend and actively participate in regularly scheduled supervision meetings and communicate any concerns to the Supervisor as necessary
- Represent the program to internal and external customers, working closely with member’s PCP and care team
WHAT YOU WILL BRING
- Minimum one year experience in community based outreach
- Bi-cultural, bi-lingual language skills strongly preferred. Spanish, Cantonese, Vietnamese or Tagalog a plus.
- Master’s or Bachelor’s Degree in a related field. Clinical supervision for MSWs may be available for up to 1200 hours.
- Associate’s degree, Certified Alcohol and Drug Abuse Counselor, or Community Health Worker certificates considered
- Previous case management and outreach experience may be substituted for educational degrees
- Experience working with people with mental illness, addiction issues, and/or homelessness
- Experience with Medi-Cal and/or Department of Health Care Services regulations preferred
- Proficient use of common Microsoft Word applications such as Word, Excel, Outlook and Access
- Because this position requires member home visits, the incumbent must successfully complete a sex offender registry screen. May be required to pass additional background checks at agency discretion.
Established in 1997, San Francisco Health Plan (SFHP) is a an award winning, managed care health plan whose mission is to provide affordable health care coverage to the underserved low and moderate-income residents in San Francisco county. SFHP is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 145,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services. SFHP was designed by and for the residents it serves, and takes great pride in its ability to accommodate a diverse population that includes young adults, seniors, and people with disabilities.
San Francisco Health Plan is an Equal Opportunity Employer (EOE) M/F/D/V
Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.