The case manager provides comprehensive case management services to all eligible patients who are high utilizers of services, individuals and families experiencing homelessness, and adults with serious mental illness, and/or substance use disorders. Reporting to the Program Manager, the case manager will be responsible for assessing clients' needs, developing tailored care plans, and coordinating a range of resources to enhance their well-being. This position collaborates closely with a multidisciplinary team to facilitate effective communication, monitor progress, and advocate for optimal outcomes.

Principle Responsibilities:

1. Collaborate with Providers, Managed Care Plans, the Housing Navigation Team, and community homeless service providers to ensure seamless care coordination for eligible patients.

2. Perform comprehensive case management services, including intake, assessment, personalized care plan development, plan implementation, subspecialty referrals, monitoring, and follow-up.

3. Connect members with essential social and support services, arranging referrals for specialized care (such as ophthalmology, behavioral health, podiatry, nutrition), transportation, housing, and more.

4. Accompany patients/clients to appointments when necessary.

5. Advocate on behalf of members when engaging with healthcare professionals, ensuring their needs are understood and addressed effectively.

6. Utilize motivational interviewing, trauma-informed care, and harm-reduction strategies to foster positive interactions and promote well-being.

7. Coordinate closely with clinical staff to establish well-structured discharge plans, facilitating a smooth transition for patients.

8. Monitor and encourage treatment adherence, including medication regimens, to support optimal health outcomes.

9. Provide valuable health promotion and self-management training to empower patients in taking charge of their well-being.

10. Collect and input essential data for reporting purposes, ensuring accurate completion of project activity and monthly reports as required by funding sources.

11. Engage in agency and community meetings to address patient needs and contribute to discussions related to Case Management concerns.

12. Participate in weekly case conferences with PCP’s clinical supervisor and peers, facilitating collaborative problem-solving for client-related challenges and ensuring the delivery of high-quality case management services.

13. Collect data for comprehensive initial and ongoing assessments of patient needs, spanning functional status, housing, mental health, substance abuse, and education.

14. Regularly update ISPs during weekly client meetings, reporting progress at case conferences to ensure goals are met effectively.

15. Provide clients with well-suited referrals for a range of services, including HIV care, housing, food, transportation, benefits counseling, mental health services, and medical support.

16. Verify clients' eligibility for public assistance programs, guiding them through necessary steps to access programs like HWLA, Medi-Cal, SSI, GR, and housing options.

17. Observe and honor information confidentiality pertaining to fellow employees.

18. Participate in designated staff, quality improvement, case conferences, and in-service meetings.

19. Fulfill other assigned responsibilities as needed.

Requirements:

1. High School Diploma or GED.

2. Experience with at least 1-year experience as care coordinator, community health worker or similar responsibilities.

3. AA or bachelor’s degree in social work, sociology or related field preferred.

4. Experience working with individuals who have multiple chronic conditions, ER visits or frequent in-patients’ admissions or experiencing homelessness.

5. Electronic Health Record experience and/ Data entry skills required.

6. Proficient in utilizing Microsoft Word, Excel and Power Point.

7. Exceptional verbal and written communication skills.

8. Proficiency in active listening and effective communication techniques.

9. Demonstrated empathy and understanding when working with clients facing challenging life circumstances.

10. Sensitivity and understanding of cultural, social, and economic diversity.

11. Strong desire to work as part of multi-disciplinary team or care coordinators, LCSW, MSW, PCP’s and MAs.

12. Medical Assistant or LVN with at least 1-year experience in case management preferred.

13. Bilingual (English/Spanish) ability strongly preferred

*All JWCH, Wesley Health Centers workforce members are recommended to be fully vaccinated and boosted against COVID-19.

Employee Benefits:

JWCH Institute, Inc., offers competitive salaries for all positions. Employees working 30 hours per week, or more are provided a monthly allowance which can be used towards medical, dental, vision, and life insurance premiums. The agency offers sick leave and vacation accrual, 13 paid holidays, jury duty pay, mileage reimbursement, employee parking, direct deposit, credit union, and an employee assistance program. In addition, JWCH offers a 401(k) Profit Sharing plan to employees who work a minimum of 1,000 hours per fiscal year.

JWCH Institute, Inc. Wesley Health Centers is an Equal Opportunity Employer.