Provide case management services for patients with complex health and social issues. Including individuals who are unsheltered, have a substance use or mental health diagnosis or are high utilizing Medi-Cal and Medi-Medi beneficiaries. The Enhanced Patient Services Case Manager will support accessing and linking patients to resources in the community. The Case Manager is responsible for enrolling appropriate participants, assessment, making appropriate referrals, appointment setting, and monitoring/reporting patients’ progress and needs, patient empowerment and utilization review and fieldwork The Case Manager will work closely with the patient’s medical team, community non-profits, hospitals and health clinics to coordinate access to primary health care. The Case Manager will also be responsible for following SCHC protocol and practices around billing, documenting case notes, and entering data regarding patient’s progress in required Case Management system. This position is responsible for working with individuals with complex health and psychosocial needs. This position is responsible for working with patients in housed and unhoused settings and in a variety of program settings, including Medical Respite.
- Performs a variety of services related to the case management of patients
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Reviews daily referrals; meet with clients in order to obtain program consent, administer required assessments, and review client’s care plan, medical follow-up and psychosocial needs.
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Work collaboratively with patient’s medical team
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Identifies needs of patients and draws from a comprehensive bank of community resources
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Follows an assessment protocol in order to assess the needs of patients
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Respects and values the patients in showing sensitivity to issues of diversity, ethnicity, gender, sexual orientation, age and disability
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Engages the patient in the development of a service plan tailored to meet the patient’s unique needs, circumstances, and preferences as determined through assessment
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Assist client in establishing individualized health goals, identifying potential problems/barriers; provide health education resources. Provide advocacy for client and monitor client’s progress.
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Coordinate logistics for health goal adherence
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Supports patient with creating a continuum of care plan to meet their physical and social needs.
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Educates the patient to make informed choices; maintains client records that include assessment plans, and case notes that are comprehensive and up-to-date
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Coordinate with Community and County Agencies involved with the homeless population
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Participates in interdisciplinary treatment team and supports patient’s ability to communicate his/her needs effectively
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Attend community meetings, as approved by supervisor
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Supports patients with transitions of care
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Document all clinical support tasks to meet data collection requirements
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Participates in Street Medicine as part of a multidisciplinary team
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If current on Medical Assistant Certification, may perform clinical duties within scope of practice.
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Other duties as assigned
- Knowledge of mental illness issues and sensitivity towards issues of diversity
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Ability to work independently and as part of a team
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Can express the mission of the Medical Respite program to other staff, patients, and to the broader community
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Knowledge of adult learning theories and group dynamics
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Ability to work in a variety of settings, including fieldwork in the community.
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Ability to manage a complex case load
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Excellent verbal and written communication skills
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Computer literacy
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Strong organizational skills
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Ability to effectively present information, respond to questions, and generally communicate clearly and respectfully with participants, coworkers, other agencies and companies
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Comfortable discussing sensitive health issues with clients
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Strong interpersonal skills. Ability to work with people with a variety of backgrounds and educational levels both in person and on the phone
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Good judgment, problem solving and decision-making skills
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Ability to uphold client confidentiality with the utmost professionalism
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Ability to travel to other offices and community locations
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Support patients in a non-judgmental way.
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Ability to complete CPR certification
- High school diploma or equivalent
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Current CA Driver’s License
- Two-Year Associate Degree or equivalent experience in Case Management
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Experience working with the homeless population
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Previous experience working in an outpatient clinic, doctor’s office, or programs for mentally ill, SUD clients
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Knowledge of harm reduction practices or theories
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Knowledge of Housing First principles
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Current CPR Certification
- Competitive Wages
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Medical Insurance
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Dental Insurance
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Vision Insurance
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403 (b) Retirement Plan with matching employer contribution
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Long-term Disability coverage
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Accidental Death and Dismemberment
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Life Insurance
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Flexible Spending Account
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Paid Vacation
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Paid Holidays
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CME with stipend
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Employee Assistance Program
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Jury Duty Pay
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Bereavement Pay
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Health Club Membership Discounts
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Prescription Discount Program
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529 College Savings Plan
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Educational Reimbursement
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Free Teledoc service for benefit eligible employees
Shasta Community Health Center is an Equal Opportunity Employer
