Case Manager

Job Title: Case Manager Job Summary: Under the supervision of the Population Health Manager, the Case Manager coordinates non-clinical aspects of patient care, emphasizing effective transitions of care, post-hospital follow-ups, and ensuring timely completion of referrals. This role exemplifies the organization’s core values—Service, Dignity, Justice, and Excellence—by fostering respectful, equitable, and high-quality support for patients. The Case Manager collaborates with healthcare providers, referral specialists, and community resources to develop personalized care plans that address both medical and social determinants of health. Utilizing electronic health records (EHR), they monitor patient progress, document activities accurately, and ensure adherence to established care protocols. They also play a vital role in meeting quality metrics such as HEDIS and FQHC clinical standards through follow-ups, preventive screenings, patient education, and care gap closures, thereby improving overall health outcomes. Key Benefits & Opportunities: Opportunity to make a meaningful impact on patient health and community well-being Growth potential within a collaborative and supportive team environment Access to ongoing training and professional development in case management and population health Work in a mission-driven organization committed to health equity and patient-centered care Essential Values-Based Competencies: Dignity: Demonstrates compassionate communication and respectful interaction with patients, families, and colleagues, upholding confidentiality and HIPAA compliance. Excellence: Commits to continuous improvement, learning, and teamwork to enhance service delivery. Service: Maintains a patient-centered approach, demonstrating adaptability and proactive support to meet individual needs. Justice: Promotes community engagement, resource stewardship, and strategic planning to address health disparities. Essential Responsibilities Patient Relations Engage cooperatively and empathetically with patients, healthcare staff, and community partners. Provide supportive communication, ensuring patient confidentiality and adherence to HIPAA regulations. Outreach and Engagement Proactively connect with patients to educate on the benefits of care management and supportive services. Follow up after hospital stays to facilitate care plan adherence and appointment attendance. Link patients to community resources addressing social determinants such as transportation, food security, and housing. Coordinate transportation and schedule in-clinic appointments to meet health and screening needs. Communicate health information clearly and accessibly, including referrals and socioeconomic resources. Case Management Conduct holistic initial assessments covering medical, mental health, substance use, and social needs, including SDOH and cultural factors. Develop and regularly update patient-centered care plans collaboratively with patients, families, and providers. Monitor progress, evaluate efficacy, and adjust plans to overcome barriers and improve health outcomes. Facilitate team communication to ensure seamless care coordination and minimize duplication. Apply evidence-based engagement techniques, such as Motivational Interviewing, to promote positive behavior change. Address emergent issues promptly and leverage critical problem-solving skills to resolve challenges. Document all interactions accurately in the EMR, ensuring compliance with legal and accreditation standards. Participate in team meetings and quality improvement initiatives to identify and address care gaps and optimize practices. Demonstrate strong ethical standards in all professional relationships. Additional Responsibilities Support clinical and community outreach activities as needed. Perform other duties assigned by supervisors. Knowledge, Skills, and Abilities Strong interpersonal skills and cultural competence across diverse populations. Ability to work both independently and collaboratively in a fast-paced environment. Excellent time management, organization, and multitasking skills. Effective verbal and written communication, including health literacy and community engagement. Familiarity with community resources and non-clinical support services. Decision-making and judgment skills, including knowing when to elevate issues. Basic understanding of behavioral health and substance use disorders. Commitment to patient confidentiality and ethical practice. Age and Population-Specific Competencies Demonstrates ability to provide sensitive, appropriate care tailored to the unique needs of the served population, ensuring equitable and respectful interactions across all age groups. Education & Experience Requirements High school diploma or GED required. At least two years of experience in healthcare or case management, preferably involving chronic illness, mental health, or substance use populations. Valid driver’s license and proof of auto insurance. Basic Life Support (BLS) certification required. Preferred Qualifications Bilingual (English/Spanish) skills. Bachelor’s degree in health, human services, or related field preferred. Certified Case Manager (CCM) or related certifications. Experience with Enhanced Care Management (ECM) programs. Licensed Vocational Nurse (LVN) with case management experience considered. Work Environment & Physical Requirements Office-based position utilizing standard equipment such as computers, phones, and office supplies. May involve extended sitting, occasionally lifting up to 20 lbs., and walking or standing as needed. Reliable transportation required for community outreach and site visits. Environment free from major hazards, with adherence to safety policies. #J-18808-Ljbffr Marquee Staffing