SisterWeb
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SisterWeb (SW) is establishing an enhanced care management (ECM) program focused on serving the Birth Equity population in San Francisco County in partnership with Anthem. The
ECM Lead Care Manager
will report to the ECM Program Director and collaborate with the larger SisterWeb team to deliver person-centered case management to birthing and postpartum members. The LCM is responsible for the delivery of the ECM program to the member, ensuring compliance with the established MCP contract. The LCM will provide case management and supportive services to individuals and families who qualify for ECM services under the Birth Equity Population definition outlined by the Department of Health Care Services in the state of California. The LCM is responsible for helping members to navigate and access community services, other resources, and adopt healthy behaviors. The LCM supports providers through an integrated approach to care management and community outreach. As a priority, activities will promote, maintain, and improve the health of patients and their families. The ideal candidate has 2+ years of case management experience and experience working in the community - possibly as a community health worker - with the Birth Equity population. The candidate should be exceptionally organized, capable of managing and prioritizing multiple tasks, collaborative, and maintain a high level of attention to detail. Ability to focus on work in the midst of other distractions, highly communicative with the ECM Program Director, others org-wide, MCP representatives, and external partners, as it is an essential function of their job. This role requires honesty, availability, and consistency in hours and time. All SW Staff are expected to honor SisterWeb's Core Values: Culturally congruent and community-centered care Economic justice and self-determination/representative leadership Respect and body autonomy Community wisdom and lifelong learning ESSENTIAL FUNCTIONS Coordinates, implements, and supervises case management services Supports case management staff in providing quality case management, navigation services, and making referrals Conducts audits of clients' files, service plans, and case notes Supervises the documentation of client services and activities Leads routine team trainings that will improve the quality of services provided to clients and support the CalAIM team’s ability to deliver services Participates in community outreach activities to bring visibility to the program and services as needed Educates members about ECM services and assists them with enrollment in services Serves as the primary liaison between the member and any services they may need Supports individuals and families as they navigate the health care system and supports the development of self-care and health care management techniques Established trusting relationships with patients and their families while providing general support and encouragement Provides ongoing follow-up, basic motivational interviewing, and goal setting with patients/families Meets members in clinic, facility, or at home to help identify social determinants of health impacting members’ health and general well-being Collaborates with the full care team to create an individualized, linguistically and culturally appropriate care plan for every enrolled member Assists members in accessing health-related services and community resources, such as accompaniment to specialist appointments and assistance with enrollment forms Facilitates communication between all parties (members, families, colleagues, and community-based organizations) as needed Helps patients set personal health-related goals and attend appointments Provides referrals for services to community agencies as appropriate Helps patients connect with transportation resources and provide appointment reminders in special circumstances Works closely with medical providers to help ensure that patients have a comprehensive and coordinated care plan Acts as a patient advocate and liaison between the patient/family and community service agencies Records patient care management information in the EMR and other software no later than 24 hours after patient contact Manages assigned caseload of patients All SW Staff are expected to meet the following work expectations, including, but not limited to: Accountability and Reliability
: Shows honesty, integrity, responsibility, initiative, and is mindful of the impact on team/organization. Collaboration:
Participate in agency-wide and/or cross-team efforts, shares knowledge and skills, values cohesion and integrity of the organization. Communication:
Respectful, effective, proactive, and willing to engage in hard conversations Continuous Learning:
Seeks out new challenges, applies new skills, shows growth. Professional Conduct:
Clear boundaries, refrains from gossip, follows agency standards per SW Handbook and SW Policies, Procedures, and Protocols. Initiative:
Commitment to seek proactive approaches to work and community. SUCCESS CRITERIA Maintains fidelity with program SOPs and compliance with MCP contract requirements Builds relationships with community partners to strengthen the network of SisterWeb’s ECM program to enable member success within the program and drive member health outcomes Commitment to data integrity and stewardship to facilitate program tracking, evaluation and quality improvement PREFERRED QUALIFICATIONS EXPERIENCE, EDUCATION AND CERTIFICATES Bachelor's degree in social work or a related field preferred 2+ years case management experience preferred Basic computer skills required; experience working in care management documentation systems and/or electronic medical records (EMRs) preferred Experience engaging clients in non-traditional care settings and/or community-based setting (i.e., in the community, in the home, etc.) Experience with medical billing and coding preferred Written and oral fluency in English and Spanish is preferred Experience working in a multi-cultural setting Willing to learn and understand a variety of different cultures, perspectives and norms Understand community resources, community connectedness Good communication skills, such as listening well, and using language appropriately Ability and willingness to provide emotional support, encouragement and motivation to patients KNOWLEDGE, SKILLS, ABILITIES Demonstrates knowledge and skill in case management and supervision, social services, and organization skills Organizes and prepares documentation in a timely manner and can handle multiple priorities while remaining professional and calm. Possess initiative, flexibility, and the ability to work under pressure without direct supervision Works collaboratively with others and a willingness to participate fully in the team process Works with many diverse people, including children and teenagers Strong level of confidentiality due to the sensitivity of materials and information handled Ability to make suggestions on workflow or system efficiency and effectiveness Ability to work independently and be self-directed and flexible Ability to work at a high-volume level of accuracy Works well under pressure in a deadline-sensitive, multi-tasking environment. Be an active collaborator and contributor to a team, but have the confidence to work independently, efficiently and proactively. Proficiency with Google Apps/G Suite, MS Office, and familiarity working with databases Must be professional and able to maintain confidentiality WORK ENVIRONMENT Work out of the SW office in San Francisco, with member home and community-based visits expected. Some days will require flexible hours, with either an early start or a late finish. Occasional weekend work to respond to urgent issues and/or logistical support for events may be required. PHYSICAL REQUIREMENTS Must be able to lift and carry up to 25 pounds Position frequently requires the ability to sit for extended periods of time Position continually requires the ability to talk and hear both in person and over the phone, visual acuity, the ability to operate equipment, read, and use a keyboard EQUAL EMPLOYMENT OPPORTUNITY STATEMENT SisterWeb is an Equal Opportunity Employer. We value a diverse workforce and an inclusive, affirming culture. We strongly encourage applications from individuals who reflect the communities we serve and who are committed to birth justice and equity. Employment decisions are based on qualifications, merit, and organizational need. We provide equal employment opportunities without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, sexual orientation, genetic information, or any other protected characteristic under applicable law. In accordance with the San Francisco Fair Chance Ordinance, we will consider qualified applicants with arrest and conviction records. This full-time position is grant funded and contingent on continued funding.
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ECM Lead Care Manager
will report to the ECM Program Director and collaborate with the larger SisterWeb team to deliver person-centered case management to birthing and postpartum members. The LCM is responsible for the delivery of the ECM program to the member, ensuring compliance with the established MCP contract. The LCM will provide case management and supportive services to individuals and families who qualify for ECM services under the Birth Equity Population definition outlined by the Department of Health Care Services in the state of California. The LCM is responsible for helping members to navigate and access community services, other resources, and adopt healthy behaviors. The LCM supports providers through an integrated approach to care management and community outreach. As a priority, activities will promote, maintain, and improve the health of patients and their families. The ideal candidate has 2+ years of case management experience and experience working in the community - possibly as a community health worker - with the Birth Equity population. The candidate should be exceptionally organized, capable of managing and prioritizing multiple tasks, collaborative, and maintain a high level of attention to detail. Ability to focus on work in the midst of other distractions, highly communicative with the ECM Program Director, others org-wide, MCP representatives, and external partners, as it is an essential function of their job. This role requires honesty, availability, and consistency in hours and time. All SW Staff are expected to honor SisterWeb's Core Values: Culturally congruent and community-centered care Economic justice and self-determination/representative leadership Respect and body autonomy Community wisdom and lifelong learning ESSENTIAL FUNCTIONS Coordinates, implements, and supervises case management services Supports case management staff in providing quality case management, navigation services, and making referrals Conducts audits of clients' files, service plans, and case notes Supervises the documentation of client services and activities Leads routine team trainings that will improve the quality of services provided to clients and support the CalAIM team’s ability to deliver services Participates in community outreach activities to bring visibility to the program and services as needed Educates members about ECM services and assists them with enrollment in services Serves as the primary liaison between the member and any services they may need Supports individuals and families as they navigate the health care system and supports the development of self-care and health care management techniques Established trusting relationships with patients and their families while providing general support and encouragement Provides ongoing follow-up, basic motivational interviewing, and goal setting with patients/families Meets members in clinic, facility, or at home to help identify social determinants of health impacting members’ health and general well-being Collaborates with the full care team to create an individualized, linguistically and culturally appropriate care plan for every enrolled member Assists members in accessing health-related services and community resources, such as accompaniment to specialist appointments and assistance with enrollment forms Facilitates communication between all parties (members, families, colleagues, and community-based organizations) as needed Helps patients set personal health-related goals and attend appointments Provides referrals for services to community agencies as appropriate Helps patients connect with transportation resources and provide appointment reminders in special circumstances Works closely with medical providers to help ensure that patients have a comprehensive and coordinated care plan Acts as a patient advocate and liaison between the patient/family and community service agencies Records patient care management information in the EMR and other software no later than 24 hours after patient contact Manages assigned caseload of patients All SW Staff are expected to meet the following work expectations, including, but not limited to: Accountability and Reliability
: Shows honesty, integrity, responsibility, initiative, and is mindful of the impact on team/organization. Collaboration:
Participate in agency-wide and/or cross-team efforts, shares knowledge and skills, values cohesion and integrity of the organization. Communication:
Respectful, effective, proactive, and willing to engage in hard conversations Continuous Learning:
Seeks out new challenges, applies new skills, shows growth. Professional Conduct:
Clear boundaries, refrains from gossip, follows agency standards per SW Handbook and SW Policies, Procedures, and Protocols. Initiative:
Commitment to seek proactive approaches to work and community. SUCCESS CRITERIA Maintains fidelity with program SOPs and compliance with MCP contract requirements Builds relationships with community partners to strengthen the network of SisterWeb’s ECM program to enable member success within the program and drive member health outcomes Commitment to data integrity and stewardship to facilitate program tracking, evaluation and quality improvement PREFERRED QUALIFICATIONS EXPERIENCE, EDUCATION AND CERTIFICATES Bachelor's degree in social work or a related field preferred 2+ years case management experience preferred Basic computer skills required; experience working in care management documentation systems and/or electronic medical records (EMRs) preferred Experience engaging clients in non-traditional care settings and/or community-based setting (i.e., in the community, in the home, etc.) Experience with medical billing and coding preferred Written and oral fluency in English and Spanish is preferred Experience working in a multi-cultural setting Willing to learn and understand a variety of different cultures, perspectives and norms Understand community resources, community connectedness Good communication skills, such as listening well, and using language appropriately Ability and willingness to provide emotional support, encouragement and motivation to patients KNOWLEDGE, SKILLS, ABILITIES Demonstrates knowledge and skill in case management and supervision, social services, and organization skills Organizes and prepares documentation in a timely manner and can handle multiple priorities while remaining professional and calm. Possess initiative, flexibility, and the ability to work under pressure without direct supervision Works collaboratively with others and a willingness to participate fully in the team process Works with many diverse people, including children and teenagers Strong level of confidentiality due to the sensitivity of materials and information handled Ability to make suggestions on workflow or system efficiency and effectiveness Ability to work independently and be self-directed and flexible Ability to work at a high-volume level of accuracy Works well under pressure in a deadline-sensitive, multi-tasking environment. Be an active collaborator and contributor to a team, but have the confidence to work independently, efficiently and proactively. Proficiency with Google Apps/G Suite, MS Office, and familiarity working with databases Must be professional and able to maintain confidentiality WORK ENVIRONMENT Work out of the SW office in San Francisco, with member home and community-based visits expected. Some days will require flexible hours, with either an early start or a late finish. Occasional weekend work to respond to urgent issues and/or logistical support for events may be required. PHYSICAL REQUIREMENTS Must be able to lift and carry up to 25 pounds Position frequently requires the ability to sit for extended periods of time Position continually requires the ability to talk and hear both in person and over the phone, visual acuity, the ability to operate equipment, read, and use a keyboard EQUAL EMPLOYMENT OPPORTUNITY STATEMENT SisterWeb is an Equal Opportunity Employer. We value a diverse workforce and an inclusive, affirming culture. We strongly encourage applications from individuals who reflect the communities we serve and who are committed to birth justice and equity. Employment decisions are based on qualifications, merit, and organizational need. We provide equal employment opportunities without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, sexual orientation, genetic information, or any other protected characteristic under applicable law. In accordance with the San Francisco Fair Chance Ordinance, we will consider qualified applicants with arrest and conviction records. This full-time position is grant funded and contingent on continued funding.
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