Case Manager - Critical Care (Bilingual Spanish)
Under the direction of the Client Services Manager-Critical Care, the Critical Care Case Manager provides in home care coordination and case management services to 25+ frail elderly and people with disabilities requiring home care services. Critical care case management is an area of specialty practice in adult and aging services. It provides intervention for medically fragile and behaviorally challenged adults and elders requiring home care services to continue living independently in the community. The Critical Care Case Manager ensures all clients receive adequate hours to meet their needs, provides crisis intervention and provider coordination, and ensures that services delivered are of high quality and in compliance with Homebridge’s contract provisions, policies and procedures, and are within the scope of the agency’s resources and mission.
Essential Job Functions
Direct Client Services
- Provides intensive care coordination services to a caseload of 25+ clients with complex personal care needs and behavioral health issues living in the community who are at risk of institutionalization
- Assists clients transitioning out of nursing facilities and back to living independently in the community, by coordinating with discharge staff and ensuring adequate home care and other supports are in place for a safe and successful transition
- Conducts visits in clients’ homes to perform Initial Assessment of clients’ needs:
- Using the number of authorized IHSS hours as a guide, determines requested hours, i.e. the number of hours of service client’s state that will meet their needs
- Based on numbers of hours requested, with the clients, defines number of hours per shift and number of shifts per week
- Assesses clients’ needs and completes Client Care Plans and Service Plans
- Has clients sign all required forms
- With Service Delivery Scheduler, creates clients’ permanent schedules, making sure Home Care Provider(s) (HCP) are matched appropriately to client and are scheduled to maximize client hours
- Coordinates Heavy Cleanings and Paramedical Care for specified clients, working closely with the Nurse Case Manager and Service Delivery Schedulers to ensure all HCPs are properly trained and paramedical tasks are regularly monitored
- Identifies changes in client’s mental, physical, psychosocial status and support systems and modifies Client Care Plans and Service Plans as changes occur; communicates needs and changes to Service Delivery Schedulers, Nurse Case Manager, and HCP’s as needed
- Provides supportive counseling to clients using Harm Reduction principles
- Provides advocacy, linkage with community resources, assists with maintenance and expansion of social network and monitors client's use of resources
- Provides crisis intervention, conflict resolution and de-escalation services
- Conducts home visits to clients every sixty days (or as needed more or less frequently) to reassess their needs, hours of service requested and Client Care Plans; documents reassessments in a timely fashion
- In the event a client cannot receive a home care shift, follows up with client, client’s support networks, APS and/or emergency personnel to ensure client is safe; makes plans to keep client safe
- Monitors hours of service delivered, quality of service delivery and client satisfaction
- Collaborates with HCP Supervisor to make sure HCP performs duties as described in the task list of the Client Care Plan
- Introduces HCP to client at first visit; reviews Client Care Plan with client and HCP
- Updates the database with Dated Notes, accurately and in a timely fashion
- Trouble shoots obstacles to providing effective home care, such as lack of cleaning supplies, client resistance, client behaviors; creates behavior contracts as needed
- Monitors hospitalizations and hospital discharge plans, ensuring home care is delivered post discharge as needed
- Based on changing client needs, facilitates hour’s changes and status changes with IHSS and the HCP Scheduler; submits documentation requesting increases or decreases in authorized hours
- Coordinates Wellness Checks and the creation of Homebridge accounts
- Reports clients who are unsafe or at-risk for abuse or neglect to Adult Protective Services
- Refers clients for resources outside the scope of Homebridge case management duties
- Complies with Welfare & Institutions Code (W&I) section 15630(a) California law (mandated reporter) requiring Homebridge employees to report known or suspected abuse of dependent adults or elders, immediately by telephone or as soon as practically possible, and by written report with two (2) working days (W&I) section 15630(b).
- Acts as Officer of the Day on a regular basis
- Receives and follows up on client complaints, initiating investigations of allegations made by clients
- Completes Assessments, Reassessments, and Dated Notes in a timely fashion
- Develops client service plans based on assessments and updates regularly
- Maintains client (hard copy and soft copy) files
- Reviews all e-mails, voicemails, and mail in real time
- Completes Bi-Weekly Timesheets and Monthly Data Form
- Actively participates in supervision, case manager team meetings, case conferences, agency meetings and other meetings as required
- In supervision, creates a personal development plan; follows up on activities in the plan
- Complies with all Homebridge policies and procedures
Knowledge, Skills, and Abilities
- Is committed to the agency’s mission to delivery of high-quality services
- Strong ability to work with complex and multi-diagnosed clients that have barriers to accepting services.
- Possesses good working knowledge of Medicare, Medi-Cal, and other entitlement programs.
- Able to identify and coordinate appropriate community services for clients
- Actively incorporates the ethical standards of the National Association of Social Workers in all aspects of interactions with others
- Able to be compassionate and empathetic with clients, often in stressful and difficult situations
- Able to develop practical and innovative solutions to client problems
- Proficient in use of Microsoft Office and able to quickly master use of proprietary software
- Able to manage time effectively, work under pressure, prioritize, problem-solve and meet deadlines
- Fosters collaboration with all departments and maintains open communication channels
- Is dependable and positive
- Is skilled at communicating in writing and verbally, both clearly and directly
Education and Experience
BSW or degree in behavioral or social sciences required. Master’s degree strongly preferred. Two years of direct experience in case management and/or working in a social service setting highly required. Experience working with populations struggling with mental illness, substance abuse and poverty is preferred.
This role will require driving at times as case load and client location demands. As such, a current Driver's License, proof of insurance, and reliable personal vehicle are required.
This position includes frequent travel to clients’ homes and work in the office, at a desk in a temperature-controlled office, in modular office space or an individual office. The noise level in the work environment is usually moderate. Frequent Travel: Must be able to travel on foot, via public transportation and personal vehicle to all parts of San Francisco for performance of job duties. May occasionally be exposed to outside weather conditions while traveling to clients’ homes. Some exposure to physical risk. Exposure to client apartments, rooms, homes and other venues so that services can be provided. May include contact with clients with mental health and/or personal hygiene issues.
The physical demands described here are representative of those that must be met by employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individual with disabilities to perform the essential functions. While performing the duties of the job, the employee is regularly required to talk or hear. The employee is frequently required to sit for extended periods at a desk or computer workstation. The employee is frequently require to stand, walk, sit, use hands to finger, handle, or feel, reach with hands and arms. The employee is occasionally required to climb or balance and stoop, kneel, or crouch. The employee may occasionally lift and/or move up to 15 pounds. Specific vision abilities required by this job include close vision, color vision, and ability to adjust focus.
How to Apply
Please send a resume and thoughtful cover letter including salary expectations to email@example.com with “Case Manager - Critical Care” as the subject. Applications without a cover letter will not be considered.
Homebridge is an equal opportunity, affirmative action employer committed to maintaining a non-discriminatory, diverse work environment.