Case Manager

Job Summary:

The Case Manager provides patient-centered case management, care coordination, and community health support to help patients overcome barriers to care and access needed medical, behavioral health, social, and community services. The Case Manager works collaboratively with patients, families, providers, the Nurse Case Manager, specialists, and community partners to promote continuity of care and support positive health outcomes. The Case Manager assists patients with social determinants of health, referral coordination, transitions of care, missed appointments, chronic disease self-management, and connection to community resources. The position serves as a liaison between patients and members of the multidisciplinary care team and provides education, navigation, motivational support, and follow-up to help patients achieve individualized health and wellness goals.

Supervisory Responsibilities:

None

Duties/Responsibilities:

• Provides patient-centered case management and care coordination to assigned patients, helping identify barriers to care, establish patient-driven goals, and connect patients with appropriate medical, behavioral health, social, and community resources.
• Assesses and addresses social determinants of health (SDOH) by screening patients, helping to identify, prioritize, and address barriers such as transportation, housing, food insecurity, financial concerns, utilities, safety, and access to care.
• Coordinates referrals and community resources by assisting patients with scheduling, completing applications, obtaining needed information, and tracking referrals through completion or resolution. When appropriate, may assist patients with or accompany them to appointments.
• Tracks emergency department visits and hospitalizations and assists with follow-up and transitions of care, including communication with the care team and connection to appropriate services and resources.
• Facilitates warm handoffs and communication between patients, families, providers, the Nurse Case Manager, specialists, internal departments, and community partners to promote continuity of care and timely access to services.
• Follows up on missed or canceled appointments and assists patients in identifying and addressing barriers that contributed to missed care, rescheduling appointments, and reconnecting with appropriate services.
• Supports chronic disease management and self-management by reinforcing provider and Nurse Case Manager education, helping patients understand care plans and instructions, supporting individualized health goals, and encouraging healthy behaviors and adherence to recommended care.
• Provides patient education, basic motivational interviewing, and goal-setting support within the scope of the position, helping patients build confidence and skills to manage their health and work toward identified goals.
• Advocates for patients and assists with navigation of health and social service systems, including helping patients identify and utilize eligible programs, benefits, and community resources to improve access to care and promote self-sufficiency.
• Documents patient contacts, care plans, interventions, referrals, follow-up activities, and outcomes in accordance with Midtown Health Center policies and procedures and participates in tracking established program and performance measures.
• Build and maintain positive working relationships with patients, families, providers, staff, community organizations, and other members of the multidisciplinary care team to support effective communication and coordinated services.
• Provide community education and resource navigation by educating community members and partner organizations about Midtown Health Center (MHC) services, eligibility and available resources. Collaborate with community partners to facilitate referrals, coordinate access to services, and assist individuals in navigating healthcare and community resources to address barriers to care.
• Maintains current knowledge of community resources, services, programs, and eligibility requirements and shares relevant information with patients and the care team; participates in quality improvement activities and performs other duties as assigned.
• Performs other duties as assigned.

Duties 1 through 13 are designated as ADA Essential Functions and must be performed in this job. All other job duties are secondary functions.

Knowledge, Skills, and Abilities:

• Ability to efficiently carry out Midtown Health’s Center mission statement and comply with its policies and procedures.
• Ability to establish and maintain effective working relationships with patients, co-workers, and the public and to be able to demonstrate cultural awareness and sensitivity.
• Must be able to maintain strict confidentiality of sensitive information in accordance to HIPAA regulations.
• Ability to comply with all occupational safety and health standards and all rules, regulations, and orders issued under the Occupational Safety and Health Act (OSHA).
• Ability to utilize critical thinking and problem solving skills to address clinic’s needs.
• Ability to interpret oral and written instructions and do appropriate follow-up.
• Ability to work independently and as a team member.
• Ability to navigate electronic health record (EHR) systems and communicable disease reporting systems.
• Ability to engage individuals and/or groups, including experience with public speaking and presentations.
• Must have exceptional time management and organizational skills.
• Must possess excellent interpersonal and communication skills in one-on-one, group, and telephone interactions.
• Ability to constructively participate in quality improvement efforts.
• Ability to actively participate in marketing and outreach activities when requested and emergency response events when required.
• Bilingual (English/Spanish) verbal and written skills highly desired.
• Knowledge of community resources and the ability to assess the need for referrals.

Education and Experience, Licensure and Certification:

• High School Diploma required
• Associate degree in Human Services or Social Work preferred
• Must successfully complete Community Health Worker training within the first year of employment.
• Must have a valid driver’s license and the ability to utilize own transportation for work purposes.

Physical Requirements:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Maintain physical condition appropriate to the performance of assigned duties and responsibilities which may include sitting or standing for extended periods of time.
• Must have the ability to exert up to 20 pounds of force occasionally and/or a negligible amount of force constantly to move objects.
• Requires frequent bending, stooping, or stretching.
• Ability to reach by extending hand(s) and arm(s) in any direction.
• Finger dexterity required to manipulate objects with fingers rather than with whole hand(s) or arm(s), for example, using a keyboard.
• Vision and hearing within normal parameters to perform job requirements.

Working Conditions/Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Ability to work varied and extended hour scheduling as requested including early mornings, evenings, and occasional weekends.
• Ability to work in a smoke-free and drug-free work environment.
• This position may work with mentally ill individuals where a high degree of stress is possible.

Other Duties:

This job description is not designed to cover or contain a comprehensive listing of duties or responsibilities that are required of the employee for this job. Duties and responsibilities may change at any time with or without notice.

EEO Statement:

Midtown Health Center is an equal opportunity employee and will consider all qualified candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability, or because he or she is a protected veteran.