Description-Under the general supervision of the Manager of Case Management Services, provides case management and health navigation services and coordinates referrals to community resources to Community Care Cooperative enrollees to positively impact the ability of families and individuals living with complex and/or chronic medical and behavioral conditions and assist them in successfully managing social determinants of health. This position uses innovative methods to enhance the multi-disciplinary team’s ability to provide high-quality, value-based care.
Representative Duties:Provides direct services for medical patients by helping them negotiate services/resources and adopt healthy behaviors:Conduct initial outreach calls to encourage enrollees and care givers to participate in care management programs,Interact with enrollees in their homes, neighborhoods, and communities as necessary, to identify and resolve member’s barriers to receiving recommended health services, adhering to treatment recommendations made by providers, and becoming effective managers of their health,Support care team members with providing in-person assistance to enrollees with self-care needs
As needed: schedule provider visits on behalf of enrollees, accompany enrollees to visits, ensure access to other community and government-based services,Guide and teach care givers about accessing appropriate levels of care,Act as an advocate and liaison between the enrollee/family and community service agencies (i.e. schools, Department Human Services, homeless shelters, hospitals, support groups, etc.)Provide ongoing follow-up, basic motivational interviewing, and goal-setting with enrollees/familiesAlong with other members of the team, conduct assessments that include the medical, behavioral, and social needs of the enrollee in order to identify gaps in care and barriers to accessing resources critical to enrollees’ wellbeing. Complete these assessments within specific timeframes,Act as a contact point, advocate and resource for enrollees, their family and their providers, building effective relationships through trust, respect and communication,Be fully accountable for the completion of work within established timeframes and for achieving the goals established for the enrollee/family,Ensure that all services are offered in a culturally and linguistically appropriate manner,Ensure that all needed accommodations are consistently made for members with disabilities,Use information about data trends for self-directed learning and performance improvement,Performs and completes administrative tasks in a timely and efficient manner:Writes case notes for each client interaction,Participates in staff and team meetings and conferences,Participates in professional activities to maintain professional standing,Participates in program reporting and accountability as required Meets agency participatory expectations:Suggests and participates in continuing quality improvement efforts,Adheres to all agency and departmental policies and procedures,Participates in quality assessment and improvement activities as requested,Adheres to the highest principles of patient and client confidentiality,Adheres to established safety policies, procedures and precautions; identifies potential or actual unsafe situations in the environment and takes measures to rectify the situation,Attends all required meetings, in-services and professional trainings,Attends all regularly scheduled research meetings, trainings, forums and pertinent FCH staff meetings,Maintains professional competence necessary to perform job responsibilities; maintains and provides agency with records of continuing education activities,Serves on agency committees and in professional organizations when requested,Performs related duties as required
Requirements-Requires a Bachelor’s Degree, BSW preferred.Relevant experience may be substituted for educational requirement.Prior case management/community health worker experience in a medical or community setting.Ability to work as part of a multi-disciplinary medical team.Experience with GLBTQ population preferred.Spanish speaking strongly preferred.Excellent interpersonal skills, communication skills and ability to be an effective team member.Work frequently off-site and ability to have a flexible work schedule, which may include evening and weekend hours.Flexibility, adaptability, independence, integrity and ability to multitask required.Enthusiasm for helping others, understanding their challenges and demonstrating compassion.Experience working with an ethnically, culturally and racially diverse work staff preferred.Ability to work harmoniously with diverse groups of individuals required
Physical Requirements:Ability to meet the following physical requirements with or without reasonable accommodations:Sit at a computer station for extended periods of time.Ability to keyboard for extended periods of time.Ability to make community visits, travel regularly and work in non-office settings.
We offer competitive salaries, and for those who qualify, an excellent benefits package; including comprehensive medical and dental insurance plans, and a retirement plan with employer match. We also provide 11 paid holidays, paid vacation, and more. LGBTQ-identified persons, people of color, and others from historically underrepresented communities are encouraged to apply.