Care Manager ( RN or MSW )

West County Health Centers (WCHC) provides comprehensive and quality health care services to the communities of Western Sonoma County. We are a cohesive team of health care providers, support staff and volunteers dedicated to wellness, affordability, and excellence of care. Come and be a part of an amazing team!3

POSITION SUMMARY: The Care Manager fulfills the goals of the CalAIM Program by managing the care of a specific population of West County Health Center patients. This population includes patients experiencing homelessness with complex health conditions. The Care Manager works directly with our Homeless Healthcare Program patients out of our Third Street House location in Guerneville. The Care Manager provides behavioral health and medical support to patients, coordinates treatment within the WCHC care teams and community partners including medical and behavioral health specialists, housing and social service agencies.

Position is a full-time, on-site role located in Guerneville, California.

RESPONSIBILITIES:

The Care Manager is an integral part of the WCHCs Primary Care Teams through the CalAIM Program:

• Works with the Primary Care teams and other staff to provide assessment, brief and on-going, solution-focused interventions and care plans.
• Coordinates the determination of patient needs based on current medical condition, living situation, financial circumstances, social support, and overall status.
• Manages two (2) Community Health Workers
• Provides support for the patient and partner/family as necessary to aid in adherence with medical and behavioral treatments.
• With direction from the primary care provider, may be requested to make home visits for homebound, sheltered or unsheltered patients requiring services.
• Accepts patient referrals from WCHC medical providers and outside referrals to begin coordination of care per the CalAIM parameters.
• Submits enrollment and disenrollment documentation using the TAR process implemented by Partnership Health Plan.
• Works together with the patient and all team members to support and further patient health, and disease management
• Coordinates with care team in tracking efforts to assure patients receive care and follow-up on necessary medical visits, outside tests, etc. at appropriate intervals.
• Engages collaboratively with community and government agencies to assure continuity and coordination of care for patients.
• Liaisons with Home Health agencies to establish and coordinate in-home care
• Coordinates medication adherence efforts
• Provides behavioral health crisis assessment and intervention when needed.
• If a Registered Nurse, provides nursing services per agency protocols.

MINIMUM REQUIREMENTS:

Education:

• Possess an MSW

OR

• Current California Registered Nurse.

Experience:

• Experience with case management preferred.
• Experience managing a team preferred.
• 1-2 years’ experience working with patient population within project area, ideally within a healthcare or community setting.
• Experience working as part of an interdisciplinary team, preferably in a medical setting
• Experience working with persons experiencing homelessness or who are at risk of becoming homeless.
• Training/experience with Chemical Dependency and multiply diagnosed individuals.
• Knowledge of community resources and networking ability.
• Must have an acute attention to detail and follow through on commitments.
• Strong organizational skills and the ability to multitask effectively in a busy environment.
• Expected to have strong interpersonal skills and can understand and follow written/verbal instructions.
• Ability to work independently with little or no supervision.
• Excellent interpersonal skills to interact positively with patients and staff alike.
• Proficiency in using office software and electronic health record systems is beneficial.

Physical Requirements:

• Must be able to perform the physical demands of the job including walking on trails in rural locations.
• Must be able to move freely about the office and neighborhood as required and carry light loads (up to 30 pounds)
• Ability to bend and move arms with sufficient range of motion to complete patient related requirements, hearing required for patient assessments, may need to assist patients onto exam table, able to lift 30 lbs., bend, kneel and twist as needed.
• Must be able to travel to various locations within the service area.
• Prolonged standing and / or sitting required.
• Ability to work with office equipment, including computers

We comply with applicable federal and state civil rights laws and do not discriminate based on race, ethnicity, color, national origin, citizenship, alienage, religion, creed, sex, sexual orientation, gender identity, gender expression, age, disability, or any other status protected by applicable laws.

Job Type: Full-time

Pay: $40.00 - $45.00 per hour

Expected hours: 40 per week

Benefits:

• Dental insurance
• Disability insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Application Question(s):

• Do you possess a Current MSW or California RN license?

Experience:

• Case management: 2 years (Preferred)
• Management: 2 years (Preferred)

Language:

• Spanish (Preferred)

Ability to Commute:

• Guerneville, CA 95446 (Preferred)

Work Location: In person

Salary : $40 - $45