Marin Community Clinics

  • Complex Care Case Manager Whole Person Care (MSW)

    Type
    Regular Full-Time
    Location
    US-CA-Novato
    Category
    Behavioral Health
  • Overview

    The Complex Care Case Manager provides ongoing case management for a caseload of MCC patients with “mild to moderate” (M2M) behavioral health concerns and other complex medical conditions and psychosocial needs, as identified by members of the behavioral health care and medical team. Complex Care Case Manager will work to fulfill the goals established by the Whole Person Care (WPC) program: to improve the wellbeing of Marin’s Medi-Cal population who are experiencing complex medical conditions and those who are homeless or precariously housed. Additionally, the Complex Care Case

     

    Manager will ensure that “high-risk” Medi-Cal beneficiaries with barriers to care get the support they need to access care and manage their social determinants of health. The Whole Person Care program adheres to the tenets of Person-Centered, trauma informed, and Housing First philosophies of care.   To this end, the case manager provides comprehensive support to his/her identified caseload of 30 patients with the goals of minimizing barriers to care, improving health outcomes, and helping patients develop the ability to manage their needs with greater independence. Working collaboratively with primary care, behavioral health, nursing and members of the care navigator team, the complex care case manager works as a member of an integrated team of professionals to provide patient-centered, outcome driven care in the context of the MCC medical home and Whole Person Care.

     

    Bilingual Spanish speaker highly desired.

    Responsibilities

    • Conducts eligibility assessments for WPC M2M case management program.
    • Conducts intakes and administer screening tools.
    • Conducts risk assessments and crisis intervention, as indicated.
    • Creates and submits comprehensive care plan that is accessible by the entire care team within 30 days of enrollment.
    • Assists Patients to complete necessary forms/applications.
    • Coordinates patient care.
    • Motivational Interviewing.
    • Teaches independent living skills as needed.
    • Work with Patients to address social determinants of health (SDOH).
    • Provides information and referrals to community resources and stay updated on current resources.
    • Consults/coordinates with interdisciplinary care team, including behavioral health, care navigation MAs, nursing, and medical providers.
    • Consults/coordinates with community partners, including attending relevant community meetings.
    • Documents all Patient interactions and services using MCC’s electronic health record AND WPC tracking system.
    • Attend WPC meetings.
    • Provide evidence-based interventions that are culturally sensitive, strength-focused, and evidence-based.
    • Timely and accurate reporting of data as requested to MCC and WPC.
    • May travel between clinics or meet Patients in the community as needed.
    • Reassessment and initiation of “step up” or “step down” process and advocate for appropriate services.
    • Attends behavioral health meetings, care navigation meetings, medical provider meetings, all-staff meetings, as scheduled.
    • Provides frank and considered opinions regarding case management services and quality improvement measures.
    • Provides guidance and consultation to junior care navigators about care navigation activities (i.e. WPC Access Navigator).
    • Provides services to satellite clinics as needed; may be asked to work variable schedule during extended-hour clinics (e.g. 10am-7pm on one or more days).
    • Other duties may be assigned.     

            

    Qualifications

    • Masters in Social Work (MSW) or Licensed Clinical Social Worker (LCSW).
    • Experience (and passion for) providing case management to individuals with behavioral health conditions, complex medical conditions and/or substance-using individuals highly preferable.
    • Knowledge of state regulations and legal/ethical standards related to client treatment, patient rights, and client/patient confidentiality required
    • Experience with/knowledge of Housing First model and/or homelessness
    • Bilingual Spanish speaker highly desired.
    • Must be able to effectively communicate with care team in person and via documentation.
    • Must be able to build relationships with patients with a variety of needs, diagnosis, and cultures.
    • WPC Case Manager must demonstrate a strong sense of empathy and compassion for those served by MCC.
    • WPC Case Manager must develop and maintain organized system of service delivery and documentation.
    • This includes efficient time management.
    • The ideal candidate must be able to triage needs and respond appropriately.
    • Must be able to think creatively to address novel situations as they arise.
    • Must be fluent in English with the ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.
    • Ability to write reports and business correspondence in English.
    • Must have the ability to effectively present information and respond to questions from clients, customers, and the general public in English.
    • Must be able to conduct clinical assessment interviews and case management interventions with patients in English.

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