AGENCY DESCRIPTION:  

Instituto Familiar de la Raza, Inc. is a multi-service community health and social service agency with an emphasis on serving the Chicano/Latino/Indígena community in San Francisco with a special focus on the diverse needs of the Mission District. Services include a wide range of mental health, HIV-related services, and social services, including health promotion, education, prevention, early intervention, case management, psychological and psychiatric interventions, and cultural/social and spiritual re-enforcement. The agency serves children, youth, adults, and families. It has a rich history of working collaboratively with other agencies to meet the needs of the Chicano/Latino/Indígena community and other cultural/racial communities in San Francisco.

PROGRAM/POSITION DESCRIPTION:  

CalAIM Enhanced Care Management (ECM) is a patient-centered program under California’s CalAIM (California Advancing and Innovating Medi-Cal) initiative, designed to provide comprehensive, whole-person care to Medi-Cal beneficiaries with complex health and social needs. The ECM program focuses on high-risk populations, such as individuals with multiple chronic conditions, serious mental health and substance use needs, or those experiencing homelessness, by offering intensive, coordinated care management and other services. Through a team-based approach, ECM program staff work closely with members, healthcare providers, and community organizations to address the medical, behavioral, and social determinants of health, connecting members to vital resources such as housing support, behavioral health services, and social services. The goal of ECM is to improve health outcomes, reduce health disparities, and promote better health and stability for vulnerable populations in our community.

The CalAIM Enhanced Care Management (ECM) Care Manager is responsible for coordinating comprehensive, patient-centered care for high-risk Medi-Cal members enrolled in the CalAIM Enhanced Care Management program. The ECM Care Manager collaborates with a multidisciplinary team to address members’ health and social needs, develop individualized care plans, and connect them with critical community resources. This role is essential in supporting vulnerable populations, including those with complex physical and behavioral health needs, homelessness, and other social determinants of health barriers, ensuring they receive tailored care and support to achieve their health goals.

Essential Job Duties include but are not limited to the following:  

Care Coordination and Care Management

• Manage a caseload of high-risk Medi-Cal members, providing person-centered care coordination and case management.
• Conduct comprehensive assessments to identify members’ medical, behavioral, and social needs.
• Develop individualized care plans that include goals, interventions, and strategies to address identified needs and improve health outcomes.
• Regularly review and update care plans based on member progress, changes in condition, and feedback from the care team.

Member Engagement and Advocacy

• Engage members through face-to-face visits, telephonic communication, and other outreach methods to build trust and support care plan adherence.
• Educate members about available services, benefits, and resources to empower them in their care.
• Advocate on behalf of members to ensure they have access to necessary services, including healthcare, housing, food, and transportation.

Service Coordination and Referrals

• Coordinate services across medical, behavioral health, and social domains, ensuring a seamless and integrated approach to care.
• Make referrals to appropriate community resources and track service delivery to address social determinants of health (e.g., housing support, food assistance).
• Facilitate care transitions, such as hospital discharge planning, and ensure appropriate follow-up services.

Multidisciplinary Team Collaboration

• Work collaboratively with ECM team members, including care coordinators, social workers, outreach coordinators, and medical providers.
• Participate in multidisciplinary case conferences, providing insights and recommendations based on member needs and progress.
• Serve as a central point of contact for members, their families, and the care team, ensuring effective communication and coordination of care.

Documentation and Compliance

• Maintain accurate and timely documentation in the electronic health record (EHR) system, capturing assessments, care plans, and progress notes.
• Ensure that all documentation meets CalAIM and Medi-Cal requirements, adhering to program guidelines and quality standards.
• Prepare reports on member engagement, service utilization, and care outcomes as required by the ECM program.

Quality Improvement and Outcomes Tracking

• Monitor and track key performance indicators (KPIs) and program outcomes, using data to identify trends and areas for improvement.
• Participate in quality improvement initiatives to enhance care delivery and achieve program objectives.
• Support program evaluation efforts by providing insights and recommendations based on care management experience.

All other relevant duties as assigned

REQUIRED SKILLS:

• Strong understanding of social determinants of health and community resources.
• Bilingual English/Spanish & Bicultural
• Ability to build trust and rapport with diverse populations, including underserved and vulnerable groups.
• Excellent organizational and time management skills.
• Proficiency in care management software and EMRs
• Effective communication, written and advocacy skills.
• Knowledge of case management practices
• Experience with collaborative work

PREFERRED SKILLS:

• Knowledge of Medi-Cal, managed care, or other public health programs.
• Experience with CalAIM or similar complex care management programs.
• Certification in Case Management (CCM) or a related field.
• Knowledge of database programs such as EPIC.

EDUCATION, CERTIFICATION AND LICENSES

• BA Degree in Social Work or in a related field or any combination of experience and/or education equivalent
• Minimum of 3 years of experience in care management, case management, or healthcare coordination.
• Experience working with high-risk populations, such as individuals with chronic conditions, behavioral health needs, or homelessness.

CONDITIONS OF CONTINUED EMPLOYMENT

• Conduct annual Tuberculosis Test
• Must pass Department of Justice Fingerprint screening
• Must provide proof of COVID-19 Vaccination upon hire (Reasonable Accommodation Requests will be considered)

PHYSICAL DEMANDS:  

The physical demands described here represent what an employee encounters while performing the essential functions of this job. Reasonable accommodations can be made to enable individuals with disabilities to perform essential functions.  

• General ability to communicate effectively in person or via telephone in a manner that can be understood by those with whom the person is speaking too, including a diverse population  
• General alertness to address emergency or potentially dangerous situations   
• Requires physical ability to remain seated at a desk for long periods of time when needed 
• Basic manual dexterity to operate work processing equipment with skill, speed, and accuracy  
• Must be able to view computer for long periods of time  
• Ability to use public and/or private modes of transportation; duties are office-based, but travel to various  offsite venues is required  
• Activities that occur infrequently are: bending, squatting, crouching, kneeling, twisting, reaching straight, above  or below shoulders  
• On occasion, must lift up to 35 LBS 

COMPENSATION AND BENEFITS²  

The salary range for this position is $31.58 to $34.92 hourly based on qualifications and experience. This is a full-time, non-exempt position at 35 hours a week with full benefits. The ECM Care Manager will report directly to the ECM Program Manager.  

All full-time positions at IFR are 35 hours per week and are eligible to participate in medical health benefit plans including dental, vision, 403(b) plan, earn vacation, sick leave, fourteen paid holidays, two paid days off (birthday and hire anniversary date) and ongoing learning opportunities.

TO APPLY:

Interested applicants should send an email to [email protected] addressed to the Human Resources Department, Instituto Familiar de la Raza, Inc. with “Care Manager – Enhanced Care Management Position” in the subject line and include the following files as attachments:

• A cover letter, indicating why you wish to join the Enhanced Care Management team and what makes you the ideal candidate.
• An up-to-date resume

Please note: a resume without a cover letter will not be considered.

Instituto Familiar de la Raza, Inc. (IFR) is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. For more information about your rights as an applicant, please see the U.S. Equal Employment Opportunity Commission poster.

For the complete nondiscrimination and affirmative action policy, please see the Civil Rights Department State of California's Discrimination, Harassment, and Affirmative Action in the Workplace policy.

² Please note that IFR reserves the right to change its benefits and contributions at any time at its sole discretion.