Are you ready to make an impact on the San Francisco community in a mission-critical, member facing role and help create systemic change?
As a Care Management Community Coordinator (CMCC) you will conduct in-person bio psychosocial assessments, create person-focused holistic care plans, and function as a liaison, coordinating services among multiple providers and community agencies, splitting time at the SFHP office and in the community (at clinics and hospitals, with community-based organizations, and home visits). You will be responsible for managing a wide range of members in a variety of different programs and participate in continuous improvement projects that will help build a more effective and efficient service delivery program model.
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 and support the implementation of member-centered, individualized 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.
- In conjunction with the Care Management nurse, support and educate individuals in: chronic condition management; medication management and adherence.
- Coordinate with the nurse to complete the member’s medical assessments and integrate the medical care plan goals.
- Act as a liaison to hospitals, long-term care settings, outpatient providers, home health representatives, and other community agencies; provide referrals to mental health care; substance use management and treatment; transportation services and other health needs
WHAT YOU WILL BRING
- One or more years of experience in community based outreach.
- 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 working with individuals with multiple diagnoses who may have multiple barriers (i.e. mental illness, substance use, access to care, and chronic medical conditions).
- Desire to work with homeless populations in their communities, including encampments, shelters, transitional housing, etc.
- Ability to quickly switch focus between community-based work and office-based work.
- Bi-cultural, bi-lingual language skills strongly preferred. Spanish, Cantonese, Vietnamese or Tagalog a plus.
- 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
- Working knowledge and use of Trauma Informed, Harm Reduction and Person Centered language and principles.
- 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.