Case Manager

Description

Salud Para La Gente (SALUD) provides high quality, comprehensive and cost-effective healthcare to underserved low-income communities in the Monterey Bay area, including Santa Cruz County and North Monterey County. We began in Watsonville in 1978 as a storefront “free clinic,” and with the ever growing need for health services, in 1992 became a Federally Qualified community Health Center (FQHC). Today we are a primary health care network with 12 clinic sites, over 400 employees and continue to provide high quality services to patients of all ages.

The Case Manager will be working under the direct supervision of the Director of Behavioral Health and Case Management. The Case Manager provides direct case management care to Enhanced Case Management (ECM) eligible patients and functions as a key member of the interdisciplinary Case Management team.

This position supports the organization's mission, vision, and values through excellence and competence, collaboration, innovation, respect, commitment to our community, accountability and ownership.  

The case manager will provide a wide range of case management services for the California Advancing and Innovating Medi-Cal (CalAIM) initiative. Duties include the development of collaborative care management plans with patients, which support patient needs in the areas of physical health, mental health, substance use disorders (SUD), community-based long-term services support, oral health, palliative care, social supports, and social determinants of health. Core ECM activities include but are not limited to, outreach, comprehensive assessment and care management, care coordination, health promotion, comprehensive transitional care, identifying patient support needs, and coordination of and referral to community and social services support. 

DUTIES & RESPONSIBILITIES:

1. Patient outreach and engagement, including referral/record review and direct communication with patient regarding Enhanced Case Management program eligibility and services
2. Determine patients' eligibility and requirements by completing comprehensive intake assessment 
3. Develop a Care Management Plan (CMP) that incorporates patient's needs in the areas of physical health, mental health, SUD, community-based Long Term Services Support, oral health, palliative care, social supports, and Social Determinants of Health. Engage and help patient participate in and manage their care
4. Care coordination and organizing patient care activities per the CMP 
5. Share and maintain information with patient's multidisciplinary team and implementing activities per CMP, including Community Supports. Communicate patients' progress by conducting interdisciplinary meetings and evaluations; disseminating results and obstacles to therapeutic team and patient family; identifying treatment influences
6. Develop, establish, and maintain professional and collaborative working relationships with internal and external care team
7. Support patient engagement in treatment including coordination or medication review and or reconciliation, scheduling appointments, appointment reminders, coordinating transportation, accompany patient to critical appointments, identify and address other barriers to patient’s engagement in treatment
8. Identify need for and coordinate access to education and training in priority clinical knowledge areas in linkage to primary care; integration of SUD care and chronic pain management; management of chronic medical and behavioral conditions; preventive care; etc.
9. Ensure regular contact with the patient and their family member(s), guardian, caregiver, and/or authorized support person(s) as part of care coordination
10. Support patient in strengthening their skills to identify and access resources to assist them in managing and prevention of chronic condition
11. Effectively manage crisis by using Motivational Interviewing and De-escalation skills, both in support of the patient and other team members
12. Provide transitional care for patients during discharge from hospital or institutional setting including developing a transition care plan, and coordination of care to provide adherence support and referrals to appropriate resources and community supports, as needed.
13. Assist patient in accessing additional benefits and related documentation such as, Social Security Insurance (SSI), CalFresh, cash aid, and obtaining required documentation to apply (ID, birth certificate, immigration status, financial records, marriage/divorce records, proof of medical conditions, etc. Facilitates referrals to Community Health Services when appropriate. 
14. Offer exceptional care coordination skills that include warm hand-offs and closed-loop referrals
15. Maintains up to date, within 24 hours of service delivery, adequate records and other documentation necessary for the collection of data and statistics pertaining to program outcomes, demographics, and information as required by funders
16. Utilizes on-going assessment skills to ensure high quality of treatment and care
17. Maintains professional competence by pursuing opportunities for continuous learning, continuing education offerings, reading professional literature, and engaging in other activities, which develop new knowledge and skills. 
18. Collaborates with Enhanced Care Management Team to build the new program workflows; implement changes; policies and procedures as appropriate in conjunction with Director of Behavioral Health and Case Management.
19. Maintains current patient records by reviewing case notes; logging events and progress effectively and efficiently in the electronic health record (EHR). Monitors patient’s treatment compliance and referral outcomes. 

20. Prepares patients' successful termination from program by reviewing and amplifying termination and treatment plans; coordinates treatment plan requirements and referrals to community resources; orients and trains family members; providing resources and notifying other providers on the health team when CMP goals are met

21. Adheres to the standards and policies of the Organizational Privacy/Security and Compliance Programs, including the duty to comply with applicable laws and regulations (HIPAA, OSHA, OIG, guidelines, and other State and Federal laws). This also includes reporting to the Board of Directors, Compliance Officer, Privacy Officer, or supervisor any suspected unethical, fraudulent, or unlawful acts or practices

22. Performs other duties as assigned

Requirements

MINIMUM QUALIFICATIONS:

• Master’ level degree in social work, psychology or related field from an accredited college/university, with a minimum of 1-2 years’ experience, preferably providing enhanced/intensive case management or health care coordination; OR
• A bachelor's degree in social work, psychology or related field from an accredited college/university with over 3 years’ experience providing case management or health care coordination.
• Strong computer skills, including able to easily navigate around health care systems
• General understanding of the complex needs of families in our community
• Bilingual in Spanish required, Bi-cultural preferred
• Must have valid CA driver’s license and clean driving record
• Ability to move between sites and perform duties in the field in a variety of settings
• Knowledge of or reasonable ability to learn use of Electronic Health Record
• Willingness to work a variable schedule, which may include evenings and Saturdays.

PHYSICAL DEMANDS:

• Standing, walking, sitting, typing, reaching, bending, moving and/or lifting up to 25 pounds.

SALARY & BENEFITS:

Salary: $64,480.00 - $78,356.12/year

 Benefits: Medical, Dental, Vision and Life insurances, Voluntary Long Term Disability, 401K, PTO and Holiday Pay.

Salud is an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, or genetic information. Salud is committed to providing access, equal opportunity and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities. To request reasonable accommodation, contact the Salud Human Resources Department, [831-728-8250, and HRDept@splg.org].

Salary : $64,480 - $78,356