The Care Coordinator/Case Manager is responsible for the coordination with primary care and behavioral health to deliver comprehensive services to patients and families throughout the continuum of care.
Bachelor’s or Associate Degree in a human service-related field or equivalent work experience. Mental illness or addiction experience helpful. Bilingual/bicultural in Spanish strongly preferred.
Representative Job Duties
Coordination and facilitation of patient care across the continuum of care:
- Proactively contacts patients with due/overdue appointments, due/overdue tests, immunizations or screenings, or unmet goals.
- Outreach to high risk patients
- Identifies patients with barriers to referrals/transition and help patients address them.
- Works collaboratively with the care team to improve and ensure quality/timely care for high risk patients
- Initiates and maintains trusting relationships with children and families
- Conduct home visits and site visits of community partners
Patient advocate/ liaison:
- Serves as point of contact for patients.
- Identifies and establishes relationships with community resources; links patients with community resources. Works collaboratively with school systems, early intervention specialists and assists in developing and increasing community collaboration and advocacy.
- Assists patients in problem solving potential issues related to referrals
- Assists patient in utilizing transportation resources to attend medical appointments.
- Works with the Enroller to help patients with obtaining health insurance
Patient support/transition of care:
- Track and support identified high risk patients when they obtain services outside of practice like emergency room, or other health care facilities.
- Assists with follow up of emergency room discharges by telephone call within 48 hours for identified high risk patients.
- Works with the Provider team to facilitate prompt (48 hours) follow-up for identified high risk hospitalized patients.
- Ensure accurate and timely documentation in Electronic Health Record.
Promotion of patient health behaviors changes:
- Follows up with patient to ensure appropriate intervals between office visits.
- Ensure that the patient and family understands the care plan and associated instructions as per protocol.
- All outreach activities are recorded in the appropriate template at the time of contact in respective patients’ EMR.
Quality improvement and performance measurement:
- Generate reports as required
- Outreaches to patients on registries and schedules appointments accordingly .
- Assist in data collection and generation of patient registry reports .
- Participate in Performance Improvement/ Continuous Quality Improvement activities as assigned.
Other Educational/Technical Assistance Duties
- As requested, attend trainings in other subject areas and report and/or provide training to SBCHC staff (and others).
- As requested, attend community and health fairs representing SBCHC’s interest
- Provide technical assistance to other SBCHC committees and assist as appropriate in the development of programs and collaterals.
Functions as member of the primary care team:
- Participates in development of patient care plans with care team
- Meets with care team on a regular basis
Competitive benefits package. Generous tuition reimbursement after 1 year of service.
Please send resumes to:
Email | firstname.lastname@example.org