FQHC Enhanced Care Manager

Job Function Summary:

Involves providing non-clinical support, guidance and assistance for patients and families as they navigate through complex healthcare environments. Primary goals are to increase patient satisfaction, and to optimize care and outcomes. Acts as a communication liaison to understand the patient's non-clinical individual needs, desires, and concerns. Guides the patient and family to a broad range of services, amenities, and information to promote healing and ensure satisfaction with the patient care experience.

Experienced professional who knows how to apply theory and put it into practice with in-depth understanding of the professional field; independently performs the full range of responsibilities within the function; possesses broad job knowledge; analyzes problems / issues of diverse scope and determines solutions.

Serves as a non-clinical resource and liaison for patients and their families. Assists with navigating all aspects of the healthcare system. Uses knowledge of the unit or clinic to resolve issues and identify ways to increase patient satisfaction. Collaborates with department managers to meet patient expectations, achieve quality outcomes and build a patient focused culture.

%

of time

Essential Function (Yes/No )

Key Responsibilities

(To be completed by Supervisor)

30

Core Responsibilities

• Patient Outreach & Engagement

• Provide ongoing care management and health coaching support for patients enrolled in disease management and care coordination programs.

• Health Education & Self-Management Support

• Resource Connection & Barrier Resolution

• Documentation & Information Management

• Collaboration & Team-Based Care

Quality & Professional Practice

25

Care Gap Closure/Care Coordination

• Conduct high-volume telephonic and occasional in-person outreach to engage patients in preventive care and disease management programs.

• Support closure of care gaps, CMS quality measures, and value-based care initiatives.

• Assess patient needs and facilitate scheduling of preventive and follow-up services.

• Build rapport with patients and caregivers to improve engagement and participation in care.

• Provide patient education regarding preventive care, screenings, immunizations, and chronic disease management.

• Collaborate with interdisciplinary teams to improve patient outcomes and organizational quality performance.

15

Longitudinal Care Management

• Provide ongoing care management and health coaching support for patients enrolled in disease management and care coordination programs.

• Utilize Motivational Interviewing techniques to promote behavior change and support self-management.

• Reinforce provider-directed care plans and patient health goals.

• Monitor patient progress, identify barriers to care, and facilitate problem-solving.

• Provide education and support related to chronic conditions, medications, lifestyle modifications, and self-management strategies

.

15

Care Coordination & Patient Navigation

• Coordinate care across providers, clinics, departments, and community organizations.

• Assist patients with appointment scheduling, reminders, transportation, medication access, and referrals.

• Support transitions of care and continuity across healthcare settings.

• Triage patient questions and facilitate resolution of administrative, financial, and clinical concerns.

• Serve as a liaison between patients, caregivers, providers, and care teams

10

Quality Improvement

• Document patient interactions and interventions in the electronic health record.

• Maintain outreach tracking systems, registries, and reporting tools.

• Support quality improvement initiatives, workflow development, and program implementation.

• Participate in training, competency activities, and ongoing process improvement efforts.

• Serve as a subject matter expert for assigned programs and workflows.

5

• Perform additional responsibilities as assigned to support departmental and organizational goals .

100%

Living Pride Standards

Service Excellence

• Demonstrates service excellence by following the Everyday PRIDE Guide with the UCSF Medical Center standards and expectations for communication and behavior. These standards and expectations convey specific behavior associated with the Medical Center's values: Professionalism, Respect, Integrity, Diversity and Excellence, and provide guidance on how we communicate with patients, visitors, faculty, staff, and students, virtually everyone, every day and with every encounter. These standards include, but are not limited to: personal appearance, acknowledging and greeting

• all patients and families, introductions using AIDET, managing up, service recovery, managing delays and expectations, phone standards, electronic communication, teamwork, cultural sensitivity and competency.

• Uses effective communication skills with patients and staff; demonstrates proper telephone techniques and etiquette; acts as an escort to any patient or family member needing directions; shows sensitivity to differences of culture; demonstrates a positive and supportive manner in which patients / families/ colleagues perceive interactions as positive and supportive. Exhibits teamwork skills to positively acknowledge and recognize other colleagues and uses personal experiences to model and teach Living PRIDE standards.

• Exhibits tact and professionalism *in difficult situations according to PRIDE Values and Practices

• Demonstrates an understanding of and adheres to privacy, confidentiality, and security policies and procedures related to Protected Health Information (PHI) or other sensitive and personal information.

• Demonstrates an understanding of and adheres to safety and infection control policies and procedures.

• Assumes accountability for improving quality metrics associated with department/unit and meeting organizational/departmental targets.

Work Environment

• Keeps working areas neat, orderly and clutter-free, including the hallways. Adheres to cleaning processes and puts things back where they belong. Removes and reports of broken equipment and furniture.

• Picks up and disposes of any litter found throughout entire facility.

• Posts flyers and posters in designated areas only; does not post on walls, doors or windows.

• Knows where the Environment of Care Manual is kept in department; corrects or reports unsafe conditions to the appropriate departments.

• Protects the physical environment and equipment from damage and theft.

Knowledge, Skills and Abilities

Req / Pref

Strong knowledge of Patient Rights & Responsibilities, Joint Commission standards, and Centers for Medicare / Medicaid regulations. Knowledge of Medical Terminology. Strong knowledge of data collection, compilation, and analytical techniques.

Req

Strong skills to comprehend and assess patient's grievances to quickly locate appropriate resources for assistance. In-depth knowledge of the organization and how to get issues resolved.

Req

Strong interpersonal and customer service skills. Ability to communicate and resolve issues effectively with a diverse population of patients, staff and physicians.

Req

Excellent analytical and problem-solving skills. Ability to develop solutions and recommend changes and follow through with implementation.

Req

Excellent written and verbal communication skills.

Req

Proficiency with Windows-based software including Microsoft word, Excel, Outlook. Knowledge of computer systems and software used in functional area.

Req

Education

Req / Pref

Bachelor's degree in related field OR an equivalent combination of education and experience with 4 years' experience as any of the following: EMT, medical assistant, health care navigator/coordinator, health educator, community health worker, social worker, or health plan care management.

Req

Certifications

Req / Pref

N/A

Licenses

Req / Pref

N/A

About UCSF

The University of California, San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It is the only campus in the 10-campus UC system dedicated exclusively to the health sciences. We bring together the world's leading experts in nearly every area of health. We are home to five Nobel laureates who have advanced the understanding of cancer, neurodegenerative diseases, aging and stem cells.

Pride Values

UCSF is a diverse community made of people with many skills and talents. We seek candidates whose work experience or community service has prepared them to contribute to our commitment to professionalism, respect, integrity, diversity and excellence - also known as our PRIDE values.

In addition to our PRIDE values, UCSF is committed to equity - both in how we deliver care as well as our workforce. We are committed to building a broadly diverse community, nurturing a culture that is welcoming and supportive, and engaging diverse ideas for the provision of culturally competent education, discovery, and patient care. Additional information about UCSF is available here.

Join us to find a rewarding career contributing to improving healthcare worldwide.

Equal Employment Opportunity

The University of California is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, protected veteran status, or other protected status under state or federal law.

Salary Information

The final salary and offer components are subject to additional approvals based on UC policy.

Your placement within the salary range is dependent on a number of factors including your work experience and internal equity within this position classification at UCSF. For positions that are represented by a labor union, placement within the salary range will be guided by the rules in the collective bargaining agreement.

To learn more about the benefits of working at UCSF, including total compensation, please visit:

Knowledge, Skills and Abilities

Req / Pref

Strong knowledge of Patient Rights & Responsibilities, Joint Commission standards, and Centers for Medicare / Medicaid regulations. Knowledge of Medical Terminology. Strong knowledge of data collection, compilation, and analytical techniques.

Req

Strong skills to comprehend and assess patient's grievances to quickly locate appropriate resources for assistance. In-depth knowledge of the organization and how to get issues resolved.

Req

Strong interpersonal and customer service skills. Ability to communicate and resolve issues effectively with a diverse population of patients, staff and physicians.

Req

Excellent analytical and problem-solving skills. Ability to develop solutions and recommend changes and follow through with implementation.

Req

Excellent written and verbal communication skills.

Req

Proficiency with Windows-based software including Microsoft word, Excel, Outlook. Knowledge of computer systems and software used in functional area.

Req

Education

Req / Pref

Bachelor's degree in related field OR an equivalent combination of education and experience with 4 years' experience as any of the following: EMT, medical assistant, health care navigator/coordinator, health educator, community health worker, social worker, or health plan care management.

Req

Certifications

Req / Pref

N/A

Licenses

Req / Pref

N/A