JOB SUMMARY:

Responsible for providing a wide range of social work and medical case management services to CBHS patients and families, with the goal of addressing social determinants of health that directly impact access to and engagement in medical care and treatment. Service delivery shall including all or many of the following: patient screening, comprehensive psychosocial assessment, service or care planning, referral and linkage to resources, progress monitoring and reassessment, crisis intervention, and supportive counseling. As a member of the medical care team, Case Managers provide consultation and support to regarding concrete needs and financial services to CBHS providers and patients. Additionally, Case Managers facilitate applications for Social Security, Medicaid and Medicare programs, and Affordable Care Act enrollment. Case Management services are made available to primary care, obstetrics/gynecological, pediatric, dental, behavioral health, LHRC, and infectious disease patients, who present with 1) general level of needs requiring routine follow-up and monitoring; 2) specialized or targeted needs requiring a specific, responsive, skilled intervention; or 3) complex needs and requiring moderately intensive monitoring and follow-up services.

MAJOR DUTIES AND RESPONSIBILITIES:

Analytical and Critical Thinking

* Provides supportive counseling for patients and families as per CBHC policy.

* Performs comprehensive intake assessments and completes all necessary documentation duties.

* Completes assigned triage and clinic duties in thorough, timely, and accurate manner.

* Provides wide range of case management and outreach services to patients and families. Case management includes comprehensive assessments, linkage to resources, planning, monitoring, crisis intervention, supportive counseling, and coordination with other team members.

* Executes aspects of assigned departmental or organizational plans specific to the provision of care and services to a diversity of patient populations and facilitating awareness of such populations.

* Facilitate psycho-educational and social/clinical support groups, as necessary for targeted CBHC patients.

* Refers and creates linkage for patients with resources provided within the CBHC service deliver system, as well as appropriate community based resources.

* Demonstrates advanced level of knowledgeable about existing community resources and how to access those resources that improve social determinants of health.

Checking, Examining, and Recording

* Coordinates information, caseload priorities, and referrals.

* Follows up on referrals in a timely, accurate manner.

* Completes referrals in a timely and accurate manner.

* Reviews patient needs, acuities, care plan, and engagement through periodic case consultation with supervisor.

Teamwork

* Works with providers, the health care team, and the community.

* Educates providers, the health care team, and the community about medical case management services through in-services and verbal or written communication.

Communication

* Participates in interdisciplinary team meetings and staff meetings as appropriate.

* Provides consultation to medical providers, other CBHC staff, and other service providers to facilitate a coordinated continuum of care

* Verbal, nonverbal, and written communications are informative and well-integrated.

* Participates in system change and promotes change within Chase Brexton Health Care.

* Ensures documentation is accessible to the patient's care team and considers that they may be accessible to the patient.

* Ensures care plan is updated addressing medical case management needs.

* Maintains accurate data for reporting to funders and partners.

* Demonstrates ability engage patients and/or families who are not engaged in services through outreach and follow up

* Develops relationships and collaborates with appropriate community resources.

Compliance, Policy, and Procedure

* Document all services as directed by CBHC policy, State requirements, and professional standards.

* Adheres to departmental and policy and procedures.

* Demonstrates appropriate use of billing, grant or orders coding for all EHR documentation.

Workplace Computers and Equipment

* Utilizes Electronic Health Record to support and improve integrated healthcare.

Willingness to Learn

* Participates in outreach activities, events, trainings, and networking and educational opportunities as appropriate.

SKILLS AND ABILITIES:

* Ability to work effectively with patients and families who have social, economic, emotional, behavioral or health problems;

* Ability to develop, initiate and follow through with an appropriate plan of service;

* Ability to provide services to patients and families and treat personal information discreetly and confidentially;

* Ability to establish and maintain effective working relationships with staff members, other agencies and the general public.

EDUCATION AND/OR EXPERIENCE:

* Bachelor's Degree in health-related field with licensure as appropriate.

* MHBE Insurance Assister/Counselor Certification within one year of hire

* Required: Three years of related experience in a health care setting and Community, case management, and/or outreach experience.

WORKING CONDITIONS/PHYSICAL DEMANDS:

Work is typically performed in an office environment.

The specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.