Lead Case Manager

Job Summary:

The Lead Case Manager provides patient-centered case management, care coordination, and community health support while serving as a resource and point of coordination for the Case Management team. The Lead Case Manager assists patients with complex medical, behavioral health, and social needs and works collaboratively with patients, families, providers, the Nurse Case Manager, specialists, and community partners to promote continuity of care and positive health outcomes. In addition to maintaining an assigned caseload, the Lead Case Manager provides day-to-day guidance, mentoring, and consultation to Case Managers; assists with complex cases; supports consistent referral and follow-up workflows; monitors established program measures; and collaborates with the Social Services Manager on quality improvement and program development. The Lead Case Manager serves as a resource to the care team and helps strengthen connections between Midtown Health Center and community resources.

Supervisory Responsibilities:

None. Provides day-to-day guidance, mentoring, and workflow support to Case Managers as assigned.

Duties/Responsibilities:

• Provides comprehensive patient-centered case management and care coordination for assigned patients, including patients with complex medical, behavioral health, and social needs, while supporting individualized goals and self-management.
• Coordinates and monitors SDOH navigation, helping patients identify and prioritize barriers to health and connecting them with appropriate community resources, benefits, programs, and services.
• Coordinates and tracks referrals to internal services, specialists, community agencies, and other resources, identifying delays or barriers and assisting Case Managers with resolution.
• Tracks emergency department visits, hospitalizations, and transitions of care, ensuring appropriate follow-up, communication with the care team, and connection to needed services.
• Facilitates warm handoffs and coordinated communication between patients, families, providers, the Nurse Case Manager, specialists, internal departments, and community partners.
• Supports follow-up on missed or canceled appointments, helping Case Managers identify barriers, coordinate rescheduling, and develop strategies to improve patient engagement and continuity of care.
• Supports chronic disease management and self-management by reinforcing education, assisting patients with care plans and health goals, utilizing basic motivational interviewing and goal-setting techniques, and connecting patients with appropriate support resources.
• Provides day-to-day guidance, mentoring, and consultation to Case Managers, including assistance with complex cases, SDOH needs, referral coordination, patient engagement, documentation, and appropriate escalation of patient needs.
• Monitors Case Management workflows and performance measures, including referrals, follow-up, ER/hospital tracking, missed appointments, patient contacts, and other established program indicators; identifies trends and opportunities for improvement.
• Supports development and maintenance of community partnerships and resource networks, maintaining current knowledge of available programs, services, eligibility requirements, and community resources and sharing information with the Case Management team.
• Facilitates collaboration within the multidisciplinary care team and serves as a resource for Case Managers in communicating patient needs, care plans, barriers, and follow-up needs among providers, families, specialists, and community partners.
• 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.
• Collaborates with the Social Services Manager on program development, staff education, quality improvement, and workflow improvement, while ensuring appropriate documentation and adherence to organizational policies and procedures.
• 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.