Older Adult Services Case Manager

Position Summary

Case Manager for Older Adults assists low-income Older Adult Zufall Health Center patients (ages 55 and older) and their families in accessing appropriate clinical and social services, including appropriate health screenings, diagnostic testing, primary medical, oral, and behavioral health care, support services and treatment, to achieve improved health outcomes. The Case Manager focuses on needs and barriers (such as financial, cultural, language, insurance) that prevent patients from achieving health outcomes. The Case Manager plays an integral role in the care coordination and management of patients and is a key member of the Care Team. Travel is expected throughout Morris and Somerset Counties to meet with patients and attend some community meetings. The Case Manager reports to the Coordinator of Older Adult Services and is a part of the behavioral health department.

Essential Functions, Duties, and Responsibilities

• Works as part of the Care Team to identify patients in need of services and communicates with the patient's healthcare team of progress of case and of unidentified needs.
• Provides in-reach to Zufall Health Center providers and other members of the healthcare team to encourage referrals for patients ages 55+

• Conducts intake process and determines clinical and social needs and coordinates plan of care for each patient.
• Provide one-time as well as ongoing case management based on the needs of the patients
• Schedules and coordinates appointments and follows up on missed appointments, rescheduling as needed. Monitors patient participation in follow-up care.
• Assists patients with arrangements for transportation, translation, and other barriers to attending appointments and accessing care. In the Older Adult population, barriers may include but are not limited to dementia, mobility issues, low motivation related to depression, and inadequate social support systems.
• Enters interventions done and plans in electronic medical record via telephone encounter or case management notes.
• Conducts home visits when indicated.
• Assists physicians and nurse practitioners with contacting patients to discuss results and additional procedures.
• Educates patients about what, why and how tests are being done. Instructs patients with preparation for all procedures
• Facilitates patient enrollment into appropriate providers, programs, services, or organizations as needed.
• Assists patients with applications for Charity Care at local hospitals, Medicaid, NJ Family Care and other benefits or insurances as appropriate.
• Increase patients sense of empowerment in their ability to navigate the healthcare system. Provide support, empathy, and guidance to patients related to their healthcare journey.
• Acts as advocate for patients with community organizations and governmental agencies.
• Establishes and cultivates excellent external referral relationships with community-based organizations who are referring or who will be referred to, as appropriate. Develops and maintains a referral resource list specific to the Older Adult population.
• Assists with tracking program enrollment, levels of services provided, collecting data, and tracking program activities.
• Works to meet program target objectives.
• Other duties as assigned.

Knowledge, Skills and Abilities

• Excellent knowledge of the health and psychosocial issues of the Older Adult population
• Excellent knowledge of available community services and resources
• Excellent communication and interpersonal skills
• Bilingual Spanish/English required
• Ability to communicate well with patients, staff and outside providers and agencies
• Demonstrate effective follow through with all tasks
• Maintain high level of confidentially
• Ability to complete assignments in a timely manner
• Working knowledge of Zufall policies and procedures, and adoption of mission and values of Zufall
• Able to work in a team
• Learn and apply the trauma informed care principles within the scope of the position
• Maintains calm demeanor and empathetic, patient-centered orientation even under stressful circumstances
• Knowledge of Microsoft Office and use of electronic medical records

Education, Training and Experience

• Bachelor's Degree in social work or related field
• Minimum of two years' experience in clinical or social service setting

Experience working with Older Adults preferred