ECM and JI Services Lead Care Manager

Description

Who We Are:

Bayview Hunters Point Foundation has been at the heart of social justice for over 50 years, providing support services for predominantly low-income people of color in the Bayview and throughout San Francisco.

Our mission is to build a community that is empowered, clean, safe, and healthy. We are focused on multidisciplinary, community-informed support for our clients, addressing the root causes of unemployment and homelessness, and advocating for the basic human rights of food, health, economic and housing security.

Today, BVHPF’s nearly 200 employees serve over 5,000 disadvantaged clients each year. Our programs include:

• Mental health counseling for youth and adults

• School-based mental health services

• Substance abuse counseling and methadone treatment

• Family transitional and supportive housing

• Rapid rehousing and flex pool housing programs

• Case management services at several homeless and housing programs

• Bayview SAFE Navigation Center

These programs are funded through nearly 20 contracts with the City & County of San Francisco, and are monitored and regulated by several authorities, including CCSF and the State and Federal government.?

Position Overview:

 The ECM and JI Services Lead Care Manager (LCM) is responsible for delivering comprehensive, member-centered case management to all populations of focus enrolled in the Enhanced Care Management (ECM) program at Bayview Hunters Point Foundation, including individuals with Justice-Involved (JI) Services eligibility. The LCM carries a full direct-service caseload, facilitates member access to health and social services, and works collaboratively with internal staff, healthcare providers, and community partners to improve member health and well-being. This position reports directly to the ECM and JI Services Program Manager. The ideal candidate brings direct case management experience, working knowledge of CalAIM and Medi-Cal requirements, and a genuine commitment to serving high-need and underserved communities. 

Duties & Responsibilities:

• Manage an assigned caseload of up to 50 members, completing up to two (2) scheduled in-person visits with each member per month. 
• Meet a minimum productivity standard of 100 billable encounters each month. 
• Serve as the primary contact for clients, coordinating care and communication with healthcare providers, social services, and caregivers. 
• Conduct comprehensive health and psychosocial assessments to develop individualized, member-centered care plans. 
• Oversee client goal setting and care plan development, ensuring plans address physical health, mental health, SUD, and other needs. 
• Ensure all comprehensive assessments and care plans are completed within 30 days of member enrollment, in accordance with program and regulatory timelines. 
• Implement and monitor member care plans, educating clients and addressing barriers to care. 
• Ensure each assigned member receives all seven (7) ECM core service components: outreach and engagement; comprehensive assessment and care management plan; enhanced coordination of care; health promotion; comprehensive transitional care; member and family supports; and coordination of and referral to community and social support services. 
• Provide mental health promotion, social work services, crisis intervention, and connection to community resources. 
• Provide responsive support that may include some weekend work, such as when a member is admitted to the emergency room (ER), to support continuity of care and transitional care needs. 
• Assist clients in navigating health services, including arranging transportation and appointment scheduling. 
• Meet with each member’s providers on a regular cadence to ensure continuity of care and keep all parties informed of the member’s progress and needs. 
• Refer members to other providers as needed to ensure they are connected to all services available to them. 
• Verify eligibility for each assigned member at the beginning of every month and mid-month to confirm continued enrollment and benefit coverage. 
• Ensure accurate and timely documentation of all services provided in accordance with Medi-Cal and Medicare billing requirements. 
• Maintain up-to-date patient health records in the Electronic Health Record (EHR) and other business systems. 
• Ensure accurate and complete data is entered into the BVHPF internal EHR for all assigned members. 
• Upload all required documents and supporting documentation into the internal EHR in a timely manner. 
• Enter all member notes and service documentation into the EHR by the end of each business day in which services are p