Case Manager

POSITION OVERVIEW:

The Case Manager provides to patients advocacy, outreach, education, clinical services. Skills and competencies required for the position include communication, cultural competence, training professional experiences, and education. The activities are tailored to meet the unique needs of the communities. Generally the position includes:

Creating more effective linkages between vulnerable populations and health care system;

Managed care and care transitions for vulnerable populations;

Providing culturally appropriate health education on topics related to chronic disease prevention, physical activity and nutrition, and cultural competence;

Advocating for underserved individuals to receive appropriate services;

Providing informal counseling; and

Building community capacity to address health issues.

The Case manager must have knowledge of community resources and counseling/social work practices with high risk populations. Case managers must have experience working with persons in crisis while attaining the ability to work independently with a strong sense of focus. Must be task-oriented, nonjudgmental and accept boundaries. The Case Manager must be able to work in a variety of settings with culturally-diverse families while having the ability to be culturally sensitive and appropriate. Maintain a caseload and meet with patients. The goal of the Case Manager is to help patients regain optimum health or improved functional capability, in the right setting. It involves assessments of patient’s condition, benefits and resources. Case managers plan and develop treatment plans with performance goals while monitoring follow up on patient care in order to meet and individual’s needs.

KEY ESSENTIAL FUNCTIONS:

• Provide care management services to patients living with chronic illnesses and their families/support systems through ensuring access to care, engagement in care coordination of care to obtain the full range of needed services.

• Gather enrollment consents, RHIO consents, and complete screening, baseline-risk assessments, reassessments, plans of care, plans of care updates and notes in accordance with HOPWA and departmental policies.

• Demonstrate the ability to clearly articulate, verbally and in writing, the aims and goals of HOPWA to potential patients, community members and staff.

• Participate in quality improvement activities, projects and reviews in collaboration with the Social Worker and Community Health Worker.

• Complete daily, weekly, monthly, or other periodic requests for narrative or quantitative data reports for program review

• Prioritize the homeless population through identification of new sources of potential patients, onsite meetings with patients at their shelter and conduct outreach and engagement presentations.

• Meet regularly with supervisor and attend staff meetings and case conferences. Be prepared to discuss case management and operational issues impacting performance and program operations.

• Complete and submit daily activity log in accordance with departmental policies.

• Maintain and u-date caseload; stratify patients into 3 categories, low medium and high risk. Provide and review list with Supervisor on weekly basis.

• Ensure patient is attending scheduled medical and social service visits through building relationships with patients and providers. Coordinate and schedule appointments with Social Worker and Medical/Mental Health providers. Routine calls should be made to internal and external providers before and after visits to follow up and provide necessary support to the patients.

• At a minimum, maintain once a month contact with each client or at a greater frequency as indicated by the risk stratification and plan of care.

• Access and respond per agency guidelines to client complaints of grievances

• Conduct outreach and engagement in accordance with HOPWA’s policies via phone, electronic methods, and letter and or field work to client/collateral/provider to engage clients or strengthen connectivity.

• Help maintain health and wellness and prevent secondary disease complications through provision of health information, support plan of care, and coaching.

• Promote and expand linkage development in all areas related to patient care including social determinants (e.g. housing, employment) and monitor the effectiveness of linkages with other service providers via phone, face to face meetings of formal case conferences.

• Communicate effectively with Supervisor in identifying strengths, weakness and opportunities of program operations

• Ensure community-follow up to engage the client in care; promote compliance with medical appointments and encourages client self-sufficiency and empowerment.

• Identify and attend training for professional development and attend departmental in-service meetings as required

REQUIREMENTS:

• HS Diploma required
• BS in Social Work or related field preferred
• Bilingual (English and Spanish) preferred
• Six years case management experience with HS Diploma/GED or four years case management experience (With AA/AS)