Care Manager I

Job Summary:

We are seeking an experienced Care Manager I who will provide community-based services to live quality independent lives in the community. The Care Manager I will work with a dynamic team of professionals who provide innovative wrap-around services including, care management, occupational therapy for fall prevention, mental health counseling, caregiver support, volunteer friendly visitors and home-based enrichment programs. Care management services are provided to individuals of all income, religious, cultural, and socio-economic backgrounds.

Key Responsibilities:

Case Management: Developing a comprehensive, individualized, person-centered care plan based on the identified clinical and non-clinical needs that address the client’s health and gaps in care and set person-centered goals.

Assessment: Conducting comprehensive assessments and re-assessments of the client's biopsychosocial needs based on program requirements.

Care Plan: Together with clients, create client-centered care plans that integrate bio-psychosocial assessment.

Care Coordination: Supporting the client to navigate, connect to, and communicate with physical & behavioral health and social systems according to their care plan.

In-Person Visits to Clients: Engaging primarily the client in-person or client’s modalities preference to assess their needs, provide support, and ensure the effective delivery of care services.

Health Promotion: Coaching the client on how to better monitor and manage their health and identify/access helpful resources.

Transitional Care: Developing a comprehensive transitional care plan to help the client transition between the emergency department, hospital, and residential/treatment facilities and developing strategies to reduce avoidable hospital admissions and readmissions.

Support System: Ensuring the client, their family, and their personal support system are informed, empowered, and connected to resources that support their health goals.

Resources Management: Identifying strategically and optimizing resources to meet the clients and their families' unique needs by referring to community and social support services.

Client Advocacy: Advocate for our clients, safeguarding their rights, preferences, and best interests as they work toward stability and self-sufficiency.

Communications: Act as the central hub of communication, ensuring a smooth exchange of information among families, healthcare providers, and all involved parties.

Documentation: Maintain detailed and up-to-date records of assessments, care plans, progress notes, and other vital documentation, adhering to legal, organizational, and NASW standards of practice. Contractual reporting requirements.

Living JFS Values: Incorporates the core JFS values into the work with clients, colleagues, volunteers and community of Welcoming the Stranger, Repairing the World, and Treating Everyone with Respect and Dignity.

Other Duties: Embrace additional responsibilities assigned by management, contributing to our collective success.

Qualifications & Skills:

Education:

• Bachelor’s degree in Social Work, Psychology, Gerontology, or Health Science.

Experience:

• At least 1 year of relevant experience related to job description.
• Familiarity with Medi-Cal, CalAIM, and community support services (preferred).
• Experience working with individuals with mental and/or behavioral health diagnoses and substance abuse disorders highly desired.
• Experience with and understanding the medical and psychosocial problems of functionally impaired adults and older adults.
• Exceptional communication and presentation skills relating to functionally impaired adults and older adults, vulnerable populations, their support systems and teams of health professionals.
• Motivational Interviewing
• Computer literacy required.

Skills and Competencies:

• Excellent interpersonal and communication skills.
• Service coordination and navigational skills
• Strong organizational and time management abilities.
• Proficiency in data entry and database management.
• Ability to work independently and as part of a team.
• Knowledge of the local community and available resources.
• Bilingual in Farsi, Dari, Spanish, Ukrainian, Vietnamese and Russian capabilities preferred.