Under the direction of the Clinic Manager, the Case Manager works as part of the Enhanced Care Management (ECM) team and Primary Care Provider (PCP) care team to provide high-quality, efficient, and service-oriented patient/member care while demonstrating the health center's core values. The Case Manager is responsible for all phases of case management.
The Case Manager uses an integrated (medical/behavioral health) case management program and a collaborative relationship-based approach, to assist poly-chronic and high-risk patients to improve health outcomes. Case Managers use a comprehensive, whole-person health assessment of the patient's current situation and status, identifies actionable barriers and obtainable goals to achieve optimal self-care management and monitors the patient's progress towards their goals.
Utilizing Camino's electronic health record system, the Case Manager is responsible for capturing, monitoring, and working all case management referrals requested by the providers. The Case Manager works closely with ECM and their care team to organize activities necessary to successfully meet requirements established by managed care plans, HEDIS clinical quality measures, and FQHC clinical performance measures.
Ensure that the core values of Camino Health Center - Service, Dignity, Justice, and Excellence are carried out within daily tasks.
Essential Values-Based Competencies
Demonstrates values-based competencies in line with the four core values that are the foundation of all activities performed by employees in order to achieve the mission of the Camino Health Center.
Patient Relations
Work diligently, cooperatively, and effectively with patients, medical providers, health center staff, and community stakeholders in all aspects of patient care and case management.
Provide positive, supportive, and caring behavior in all communications to patients, community stakeholders, and staff.
Maintain patient confidentiality and HIPAA practices at all times.
Outreach and Engagement
Provide a patient orientation to those that are referred to case management, explain what the benefits are, and how it will support them in addressing their health care needs.
Identifies specific times to connect with the patients, to inquire or provide needed updates, in person or over the phone.
Communicates and delivers easy-to-read information about health and wellness, referrals to specialists, and other community resources that may be beneficial to the patient.
Shares socioeconomic resources that may benefit the member and addresses important items such as food insecurity, sheltering needs, etc.
Identifies opportunities to schedule in-clinic appointments to address various health needs/screenings; arranges transportation as needed to and from the clinic.
Case Management
Works closely with the Primary Care Provider (PCP) teams, Enhanced Care Management (ECM) team, Behavioral Health Specialists (BHS), and Referral Specialists.
Engage patients with medical, mental health, and/or substance utilization disorders in health support services utilizing evidenced-based engagement skills.
Conduct initial holistic health assessment of the patient's current conditions, situation, and needs and performs ongoing evaluations.
Assessment will include evaluating the patient's social determinants of health (SDOH) and cultural influences on health care practices.
Collaborate with the patient, caregivers, and providers to develop a patient-centric case management plan that addresses barriers and promotes improved health outcomes.
Monitor and evaluate the effectiveness of the patient's care management plan and continuously updates to ensure goals are progressing and remain pertinent, adjust goals as needed, and identify/address barriers to completing goals.
Facilitates communication and coordination among the health care team to minimize fragmentation, eliminate duplication, and maximize delivery of appropriate care.
Provide interventions focused on removing the patient's barriers to health improvement, promoting positive behavior change using Motivational Interviewing techniques, and addressing the caregiver's/family member's needs in order to stabilize the patient's natural support system.
Works in the moment to address arising issues brought forth by the providers, staff, caregivers, and family members; must leverage strong problem-solving skills to overcome challenges in the patient's case management.
Uses the electronic medical record (EMR) system to accurately track the progression of the patient's case management.
Maintains concise, accurate, and timely documentation that supports effective, efficient management of the member and that meets accreditation, contractual, and legal requirements.
Participates in weekly case review to discuss patient challenges and seeks input from peers and providers on potential solutions to current issues/barriers to care.
Engages in quality improvement initiatives and projects, such as identifying and addressing gaps, and developing/testing new practices to improve case management outcomes.
Models the highest ethical behavior in relationships with co-workers, supervisors, members, providers, and colleagues in the community.
Participates in all appropriate staff meetings or other activities as needed.
Additional Responsibilities
Performs other duties as assigned by supervisor.
Minimum Position Qualifications