ECM Case Manager

Position Title:                  Case Manager  

Department:           Care Management Services Department

Position Reports to:   Care Management Services Program Manager

Status:                             Full-time/Non-Union  

Summary: The Case Manager works as a team member of the Care Management Services Department that works to provide care management, coordination, and supportive services to Clinica Romero patients. The Case Manager will work with individual patients to develop personal goals, person-centered care plans, and support patients in meeting their goals. The Case Manager will use the “whatever it takes” approach to help patients get connected to resources and supportive services that support health outcome improvement. This can include, but is not limited to, resources related to transportation, food, specialty medical care, legal services, and housing. The Case Manager will report to the Care Management Services Program Manager.

Duties and Responsibilities:

Provides support, empowerment, education and case management services to patients to ensure improved health outcomes.

Conducts periodic assessments of patient’s progress with the developed care plan, related goals, and needed services.

Provides support and assistance to patients with accessing resources in the community.

Educates patients with chronic illness about evidence-based standards of care and self-management of their chronic illness.

Educates patients about the health care system and facilitates relationship building between the two.

Documents work with patients through appropriate record keeping that follows the project’s policies and procedures.

Listens attentively to patient needs and suggestions and addresses their issues fairly and professionally, and coordinates with immediate supervisor for supervision.

Develops and maintains strong ties to the community, local community-based organizations, and government program offices.

Links patients to appropriate social service resources and medical care programs, and assists them in completing required paperwork in order to enroll them.

Links patients to specialty healthcare services including but not limited to mental health, substance use disorder, dental, transportation to access healthcare services, and other resources as needed.

Participates in staff meetings, trainings, conferences, program evaluation and program development.

Serves as support to primary care team to ensure patient follows care plan as specified by the primary care provider.

Keeps highly organized files for each patient and enters appropriate data into the clinic’s EHR system (Epic).

Participates in case conferencing meetings and other community meetings.

Coordinates with other outreach teams in joint outreach efforts.

Perform follow-ups and wellness checks on existing patients.

Assists and supports patients in maintaining cooperative and effective relationships with case managers and other service providers.

Coordinates social, educational, and other activities/appointments for patients.

Provides specific information about public assistance programs for health and social services to which patients may be entitled.

Develops a written care plan specific to patient needs.

Qualifications

Fluent in Spanish.

Knowledge and experience in social work, healthcare, community outreach, or human services.

Degree from an accredited college or university in social work, human services or a related field (highly preferred).

Must be highly motivated and a self-starter. The ability to communicate with and relate to a diverse group of people including patients, community, and other staff.

Excellent organizational skills and the capability to work in a fast-paced environment.

Strong knowledge of social services and resources.

Effective crisis management skills.

Proficiency in MS Office Suite (Word, Excel, PowerPoint, Outlook)

Ability to accurately enter data in to CMOAR databases (EPIC/OCHIN)

Valid California Class C Driver License or the ability to utilize an alternative method of transportation when needed to carry out job-related essential functions.

Valid automobile liability insurance.

Travel is required for external homeless outreach events and/or as needed between clinic sites.