Care Manager II - Bilingual-English/Cantonese required (Full time)

PACE Program - LIFEWAYS San Francisco, California


You may think “old” when you think of Institute on Aging because we offer services for elders and are a 40+ year institute…. but you wouldn’t be more wrong. While we do have a long-standing history in the Bay Area, IOA is on the forefront of revolutionary healthcare models, reshaping the way people can age in place. Our innovative models transform lives, enhance communities, and save healthcare systems millions of dollars. Rather than focusing on archaic outdated design, we strive to consistently question the “status-quo” and create new and more innovative ways to help aging adults maintain their quality of life. With over 23 programs, we offer multiple ways to aid seniors maintain their health, well-being, independence and participation in the community, fulfilling our mission.

On Lok Lifeways pioneered the model of care known as "Program of All-inclusive Care for the Elderly" or PACE. Institute on Aging operates a PACE Center in the Richmond District of San Francisco. PACE allows seniors who are ill or disabled to live in their own home, whether home is a family residence, apartment, retirement village or hotel room.

The PACE Lifeway’s Department is seeking a Care Manager II to join its team in San Francisco. Responsibilities include: 

  • Conducts comprehensive assessments and on-going re-assessments of the client including psycho social, physical and mental health, environmental and spiritual needs.
  • Writes comprehensive assessments.  Based on assessment information with the client develops and initiates the Community Living Plan, which is client-centered, comprehensive and consistent with program guidelines and policies and procedures.
  • Conducts home visits, acute hospital & skilled nursing facility visits, as well as escorts clients to medical and other appointments as clinically indicated.
  • Identifies, arranges for, and monitors appropriate community services based a good knowledge of Medicare, Medi-Cal, and other entitlement programs.
  • Establishes and maintains a care management relationship with clients and their significant others as appropriate, offering respect, dignity and support. Provides crisis intervention, advocacy, problem solving and therapeutic interventions.
  • Meets with clients at least monthly, and more often as clinically indicated.  Reviews and modifies their care plan on an ongoing basis.
  • Documents via progress notes all case management activity regarding identified problems within 24-48 hours, adding any new problems to the care plan, as needed.
  • Maintains required paperwork and follows a clear, concise, and consistent system of charting to allow for continuity of care.
  • Ongoing evaluation for client Purchase of Service needs and follow-up to determine if services have been provided in a timely manner.
  • Educates clients and significant others about resources.
  • Establishes and maintains open and effective communication with community providers, including physicians and other health care and social service workers.  Provides appropriate information on all significant aspects of individual client care and program operations, while maintaining necessary confidentiality.
  • Monitors the quantity and quality of the services provided by other involved providers.
  • Working closely with the team, continuously evaluates the clients’ ability to remain safely at home; coordinates placement as appropriate, according to Community Living Fund guidelines.
  • In collaboration with the client, caregiver, and involved services, terminates clients when appropriate. Documents the process as required.
  • Participates in research studies and data collection, as required.
  • Participates in and promotes ongoing efforts towards Continuous Quality Improvement.
  • Attends and actively participates in team and program meetings, activities and problem-solving endeavors; contributes to open lines of communication within the team.
  • Utilizes supervision appropriately; maintaining open lines of communication and providing updates on caseload activity.
  • Actively incorporates the ethical and legal standards of the National Association of Social Workers into all aspects of interactions with others.
  • Understands and applies the regulatory and procedural requirements of Community Living Fund as well as the policies and procedures of the Institute on Aging.
  • Attends continuing education classes and/or Inservice training to increase knowledge, skills and attitudes related to case management, gerontology, family and community systems and other areas relevant to the Community Living Fund client population.

  • Masters’ Degree in Social Work (M.S.W.)
  • One year working with disabled adults and/or older adults
  • Experience with and understanding of the medical and psycho social problems of functionally impaired adults and older adults
  • Exceptional communication and presentation skills relating to functionally impaired adults and older adults, their support systems and teams of health professionals.
  • Demonstrates case management skills and experience in the community health care delivery system.
  • Detail oriented with good problem-solving skills and the ability to prioritize multiple tasks.
  • Computer literacy
  •  Bilingual-English/Cantonese literacy


  • Experience working with individuals with mental and/or behavioral health diagnoses and substance use disorders

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Institute on Aging reserves the right to revise job descriptions or work hours as required.

Institute on Aging is an Equal Opportunity Employer. Institute on Aging is committed to cultivating a diverse and inclusive work environment and providing equal opportunities to all employees and job applicants without regard to age, race, religion, color, national origin, sex, sexual orientation, gender identity, genetic disposition, neuro-diversity, disability, veteran status or any other protected category under federal, state and local law.