Community Bridges envisions a thriving community where every person has the opportunity to unleash their full potential. Our family of ten programs delivers essential services, provides equitable access to resources, and advocates for health and dignity across every stage of life.

POSITION DESCRIPTION:

Under the direction of the Enhanced Care Management (ECM) program manager and the ECM program supervisor, and working as part of an interdisciplinary team, the lead care manager (LCM) is responsible for coordinating person-centered services and comprehensive care management with Medi-Cal recipients who have complex medical and social needs. The LCM engages community members and helps individuals navigate/access community services and resources, and adopt healthy behaviors. The ECM program is a community-based care coordination program addressing social determinants of health to bridge service gaps and improve health outcomes for Medi-Cal recipients.

DUTIES AND RESPONSIBILITIES:

Care Management:

• Provides comprehensive assessment of identified clients/members.
• Develops person-centered care plans based on assessed client needs and goals.
• Ensures the implementation of the assessment and care plan.
• Provides direct care management services to clients in the Enhanced Care Management program.
• May work collaboratively with ECM CHWs, as needed, to ensure implementation of care plan.
• Forms authentic partnership with clients, uncovering what impedes better health outcomes, and actively works to find solutions.
• Engages potential clients in health promotion and self-management.
  • Engages clients and builds trusting relationships
  • Screens for and identifies social and behavioral health needs
  • Arranges/assists with linkages to care, including appointments, transportation, etc.
• Meets clients where they are – in their homes, at health care offices, in the community.
• Assists with facilitating clients’ use of technology to conduct virtual visits when needed.
• Supports clients in developing health literacy; provides health promotion materials.
• Advocates for clients with health care professionals; encourages treatment adherence; collaborates and coordinates with health care providers.
• Accompanies clients to medical visits, as needed.
• Works collaboratively with interdisciplinary team of nurses, social workers, and therapists.
• Participates in case conferences and interdisciplinary team meetings to improve clients’ health outcomes.
• Maintains accurate and timely care management records, including assessments, home visits, person-centered care plans, periodic reassessments, and progress notes related to client goals and interactions in the electronic health record (EHR).

Outreach and Community Connection:

• Lead in developing outreach plans and engaging new clients/members.
• Builds and uses a community resource network for support with housing, food insecurity, employment, childcare, etc., develops and implements creative and resourceful strategies to meet client’s needs.
• Conducts a variety of outreach activities to connect with potential clients.

Professional Conduct:

• Maintains confidentiality and treats participants and staff with dignity and respect at all times.
• Communicates effectively and respectfully with people from diverse racial, ethnic, and cultural groups and from different backgrounds and lifestyles; demonstrates compassion and sensitivity to their needs.
• Develops and maintains positive community relationships with clients, coworkers, supervisors, partners, stakeholders, and the public.
• Performs other duties as assigned.

Job descriptions are intended to be illustrative only; they are not designed to be restrictive or to define each and every assigned duty and responsibility. In an organization of this nature, each employee is expected to perform such duties as necessary to fulfill the stated goals of the agency.

We screen all applicants, require background checks on final candidates consistent with funding regulation requirements and are a Drug-Free Work Place.

UNION:

The lead care manager position is represented by the SEIU bargaining unit.

OTHER JOB DETAILS:

• This is a FLSA non-exempt position.
• This position is eligible for a $.40/$.10 per hour bilingual/biliterate differential after passing a test administered by the HR department.
• This position is both on-site and, in the field, and may allow some remote work.
• Hours of work are typically Monday-Friday between 9-5, however some evening and weekend work may be required.

MINIMUM QUALIFICATIONS:

Required:

• Must meet one of the following requirements:
  • Have a bachelor’s degree in social work, health and human services, or other related discipline and obtain a Community Health Worker (CHW) certificate of completion (2 classes) within one year of hire OR
  • Hold a CHW certificate of achievement (16 units, including internship/practicum) at time of hire.
• Understanding of person-centered services and social determinants of health
• Ability to develop, implement, and update care plans
• Ability to be persistent, creative and resourceful in locating meaningful community resources and implementing care management plans
• Demonstrates a high level of tolerance and empathy for individuals who present for services with urgent multiple care management and health needs
• Strong interpersonal skills and the ability to work with individuals struggling with high level mental and physical health conditions, including navigate complex personalities, challenging behaviors, and sensitive situations with composure and resilience
• Ability to grow and learn along with the program
• Bilingual English/Spanish.

Preferred:

• Experience with chronic illness
• Familiarity with motivational interviewing techniques, de-escalation techniques, and trauma-informed care.

Other Requirements:

• Must pass a TB test before first day of employment.
• Must receive an annual influenza vaccination or be willing to wear a protective face mask during government regulated influenza season.
• Must have a valid CA driver’s license, drive a motor vehicle incidental to the performance of the work and be insured.
• Lead Care Managers may transport clients and must pass a pre-employment drug screen and comply with periodic testing for drug use and alcohol misuse.
• Must be able to work at a computer for full workdays; some routine lifting and reaching requirements.
• Must pass a criminal background check and maintain a clean record.