BACKGROUND INFORMATION:
The Center for Community Health (CCH) represents an exciting opportunity for Tulsa. The goal is to improve health disparities in the Tulsa community, decrease re-admission rates and inappropriate emergency room usage, and increase the use of primary care providers to improve Saint Francis Health System (SFHS) patient health outcomes.
POSITION SUMMARY:
Provides services to bridge the gap between Center for Community Health clients and community health services by: Coordinating referrals to community agencies for additional assistance, treatment, and continuity of care. Completes electronic documentation of each client contact. CMs will work closely with medical providers and primary case management teams at SFHS, Laureate, and other agencies to improve client care and outcomes. CMs will primarily work out of SHFS patient rooms and have office space at SFHS and/or Laureate. CMs will implement effective strategies for linking high risk uninsured and underinsured clients to primary care/medical homes; increase access to appropriate health care and community-based services; assist individuals in improving health status; and promote behavior change in using the health care delivery system.
The following functions represent most of the duties performed by the position but are not meant to be all-inclusive or prevent other duties from being assigned when necessary.
ESSENTIAL JOB FUNCTIONS (95% of Time):
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Build trust and rapport with high-risk patients through bedside screening and engagement in hospital, emergency department, and behavioral health inpatient settings.
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Provide focused case management by linking enrolled clients to the most appropriate venue for entry into the health care delivery system to include addressing the social determinants of health: transportation, primary care provider, food, utilities, health insurance, medications, housing, domestic violence, and access to internet, phone, and identity.
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Coordinate care with SFHS physicians, case management, and other staff to provide coordinated screening for referred patients.Work with a multidisciplinary health care provider team. Participate in weekly meetings and visit identified patients in the hospital before discharge.
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Coordinate as needed with Tulsa Health Department (THD) services and community partner resources.
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Engage clients through home visits and meet clients in community-based settings such as shelters, hospitals, clinics, and partner agency sites, to deliver outreach, support care coordination, and address social determinants of health.
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Participate in and attend regularly scheduled supervision meetings; be prepared to share both successes and pitfalls of case management.
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Provide culturally and linguistically appropriate services to assigned clients.
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Maintain complete and accurate documentation of all activities and reports through computerized data entry in accordance with program standards, guidelines and THD requirements. This includes preparing and submitting paperwork, such as, Workflow List, Enrollment Questionnaires, Client Summaries, and Weekly Caseload List.
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Attend regular peer group meetings for networking and information sharing for optimal care management and navigation.
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Other duties as assigned including those required to fulfill activities in support of public health emergency operations.
SECONDARY JOB FUNCTIONS (5% of Time):
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Participate in staff meetings, quality assurance activities, and in-service trainings.
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Complete monthly time sheet and mileage forms.
Education:Bachelor’s degree required. Health care, social work, or public health background or education preferred.
Experience:One-year experience in health care, social work, or public health preferred. Previous experience with low-income individuals and engaging culturally diverse individuals in health and social services is preferred.
Knowledge and Skills:
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Bilingual in English/Spanish is preferred, but not required.
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Must have ability to work quietly and respectfully in a shared workspace.
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Excellent interpersonal and communication skills are required to provide effective health counseling and obtain cooperation from individuals who come from a wide range of economic, social, and ethnic backgrounds.
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Demonstrated comfort working in hospital and behavioral health settings and interacting with individuals experiencing physical, behavioral, or mental health challenges.
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Skill in operating a personal computer and smart phone applications.
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Understanding of healthcare delivery processes.
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Skills in obtaining and protecting personal health information (PHI).
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Effective interpersonal skills in working with personnel at all organizational levels.
Licenses/Certification:
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Valid Oklahoma driver’s license required
INTERNAL AND EXTERNAL WORKING RELATIONSHIPS:
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Regular internal contact with various nurses and case managers to coordinate care or referrals for patients.
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External contact with community partners for the coordination of care and referrals for clients.
PHYSICAL EFFORT:
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Requires frequent mobility throughout a high-volume hospital environment, including travel between patient rooms, clinical units, and multiple floors.
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Ability to visit clients’ homes, conduct interviews, attend meetings, sit for extended periods, and pick up and deliver transportable medical equipment, ie. briefs, shower chairs, wheelchairs, etc.
SUPERVISORY RESPONSIBILITY/ACCOUNTABILITY:
Direct Supervision – None
Indirect Supervision – None
Budget/Money/Material – Responsible for assigned computer hardware and software
Reports to – Manager, Center for Community Health
Location – St Francis Health System
WORKING CONDITIONS:
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Exposure to hospital environments and individuals with physical, behavioral, or mental health challenges; must follow safety and infection-control procedures.
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Exposure to stressful or emotionally charged situations common in healthcare settings.
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Performs additional work in office spaces at SFHS/Laureate and in community locations such as homes, shelters, and partner sites.
SPECIAL REQUIREMENTS:
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Must maintain THD record confidentiality according to HIPAA regulations.
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Must possess ability and willingness to perform job-related travel
FLSA Status: Non-Exempt
