ECM and JI Lead Care Manager

Description Position Overview: The ECM and JI Services Lead Care Manager (LVN) 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 provided.
• Conduct self-audits every 90 days for each assigned member to ensure documentation accuracy and ongoing compliance with program, CalAIM, and CARF standards.
• Assist with preparation for external audits, gathering and organizing member records and documentation as needed.
• Complete monthly reporting to ensure program compliance with funding and regulatory requirements.
• Monitor and adhere to billing procedures, ensuring alignment with state and federal regulations.
• Maintain working knowledge of Justice-Involved (JI) Services, including the number of encounters that can be billed for JI services and the applicable billing requirements.
• Understand the needs of the JI population of focus and tailor outreach, engagement, and care coordination to serve them effectively.
• Conduct outreach and engagement activities to connect with eligible and interested members, explaining the program and service offerings, and log all activity in the EHR system.
• Complete the intake process for members assigned to their caseload, ensuring timely enrollment and orientation to the program.
• Provide clinical guidance in implementing evidence-based practices, such as Motivational Interviewing and Trauma-Informed Care principles.
• Perform administrative tasks using HIPAA-compliant systems for remote work.
• Respect patient confidentiality and uphold HIPAA compliance.
• Adhere to BVHPF’s Lone Worker Policy at all times when conducting field-based work, including the consistent use of the assigned personal safety device to ensure staff safety during community and home visits.
• Attend required training sessions, actively contribute to team development, and maintain strong working relationships with internal staff and external partners.
• Utilize video conferencing tools frequently for remote collaboration.
• Provide coverage for additional members as directed by the Program Manager when a colleague is out, to support continuity of services.
• Perform other duties as assigned. Requirements Required

Qualifications:
• Must possess a current State of California LVN license in good standing, with required professional liability insurance.
• Bachelor’s degree in Nursing, Social Work, Public Health, or a closely related field.
• A minimum of three to five years of direct case management experience, with demonstrated ability to manage complex caseloads and coordinate services across systems.
• Working knowledge of care coordination, chronic disease management, behavioral health integration, social determinants of health, and community-based resources relevant to the populations served.
• Familiarity with the Enhanced Care Management (ECM) and Justice-Involved (JI) populations of focus, including a clear understanding of the distinction between justice-involved and justice-impacted individuals and how that distinction shapes service delivery.
• Ability to navigate case management software, electronic health records (EHR) systems, and data reporting tools with accuracy and consistency.
• Strong written and verbal communication skills, sound organizational practices, and the ability to engage effectively within a multidisciplinary team environment.
• Demonstrated ability to work effectively and respectfully with individuals from diverse cultural, linguistic, and socioeconomic backgrounds.
• Ability to work effectively with diverse, underserved, immigrants and minority communities.
• Demonstrated flexibility, initiative, and ability to function as a proactive team member.
• Ability to work independently, while also seeking supervision and guidance when appropriate.
• Strong organizational skills, including the ability to prioritize, multitask, and meet deadlines
• Dependable, adaptable, and able to work effectively under pressure; receptive to change and cooperative in problem-solving situations.
• Regular and reliable job attendance.
• Effective verbal and written communication skills.
• Proficiency in computer skills, including knowledge of Microsoft Office, Avatar, internet browsers, etc.
• Exhibit respect and understanding of others to maintain professional relationships.
• Independent judgement in evaluation options to make sound decisions.
• Ability to work effectively in an open office environment surrounded by moderate noise and distractions.
• Frequently required to sit; occasionally walk and stand; travel from the building to other sites.
• Specific vision abilities required by this job include close vision, distance vision, depth perception, and the ability to adjust focus.
• The employee must be able to meet deadlines with time constraints.
• May be asked to occasionally work irregular or extended hours while performing job duties.
• Valid California’s Driver’s License (if duties require).
• Able to meet required state, federal, local and BVHP standards.
• Live Scan fingerprinting and TB clearance as well as any other medical vaccinations may be required.
• At least two COVID-19 vaccinations (preferred). Physical & Additional

Requirements:
• Regular and reliable job attendance.
• Effective verbal and written communication skills.
• Proficiency in computer skills, including knowledge of Microsoft Office, Avatar, internet browsers, etc.
• Exhibit respect and understanding of others to maintain professional relationships.
• Independent judgement in evaluation options to make sound decisions.
• Ability to work effectively in an open office environment surrounded by moderate noise and distractions.
• Frequently required to sit; occasionally walk and stand; travel from the building to other sites.
• Specific vision abilities required by this job include close vision, distance vision, depth perception, and the ability to adjust focus.
• May be asked to occasionally work irregular or extended hours while performing job duties.
• Able to meet required state, federal, local and BVHP standards.
• Live Scan fingerprinting and TB clearance as well as any other medical vaccinations may be required.
• At least two COVID-19 vaccinations (preferred).
• As part of our commitment to maintaining a secure environment, all candidates selected for this position will be subject to a comprehensive background check clearance. This clearance is a standard part of our employment process and is conducted in accordance with applicable laws and regulations. As part of our commitment to maintaining a secure environment, all candidates selected for this position will be subject to a comprehensive background check clearance. This clearance is a standard part of our employment process and is conducted in accordance with applicable laws and regulations. Work

Location:
Onsite and Field-Based in San Francisco, CA 94124 EEO STATEMENT: Bayview Hunters Point Foundation is a welcoming space for all, regardless of race, gender, sexuality, country of origin, religion, or ability. Candidates from a diversity of backgrounds are strongly encouraged to apply. Bayview Hunters Point Foundation is an Equal Employment Opportunity Employer.