Case Manager

                                                                             La Clínica del Pueblo

                                                                             Job Description

Job Title: Case Manager

Department: Health Equity

Supervisor: Community Partnerships Manager

Location: The position will work in Washington, DC and Hyattsville, MD.  Will be working in both locations.

Classification: Non-Exempt/Hourly

Synopsis:

The Case Manager connects patients to essential health, social, and community-based resources. They

serve as a link between patients and needed services by facilitating access and troubleshooting barriers

to resources. Additionally, they support patients by creating action plans that enhance their ability

to self-navigate systems and coordinate care both within the organization and with external services.

Qualifications:

Required Education and Experience:

• High School diploma, G.E.D or equivalent.
• More than two years of experience working in Health & Human Services.
• Bilingual in English and Spanish.
• Excellent oral and written communication skills in English and Spanish.
• Proficiency with Microsoft Office; advanced skills in Microsoft Excel.
• Experience in care coordination and/or case management.

Preferred Education and Experience:

• Proficiency with Electronic Medical Records (EMR).
• Experience working with Limited English Proficient populations.
• Experience working with people living with HIV, and other Chronic Conditions.
• Local knowledge about and connections to community health care and social welfare resources.
• Highly organized with the ability to keep accurate notes and records.
• Core values consistent with a patient-centered approach to care.
• Experience working in a dynamic and fast-paced team environment.

Duties and Responsibilities

Implement individualized action plans for patients assigned to case management, including the following services:

• Manage a high volume of complex care caseloads that include proactive outreach and documentation of encounters in EMR, including Ryan White and My Health GPS and other programs for complex care coordination.

• Provide benefits counseling and support to assist eligible clients in obtaining access to public and private programs for which they may be eligible, including but not limited to AIDS Drug Assistance Program, Pharmaceutical Manufacturer’s Patient Assistance Programs, other state or local health care, and supportive services.

• Aid patients in filling out forms on the spot to increase the likelihood of completion.

• Troubleshoot medication access, including filling out forms, submitting to appropriate channels, and contacting pharmacies.

• Assist patients in navigating health, behavioral health, and social service systems, including housing supports as needed.

• Conduct telephonic outreach and follow-up for patients who do not require in-person visits.

• Administer the Health-Related Social Needs Screening (PRAPARE) as required.

• Ensure accurate, timely, and consistent documentation of services in the electronic medical record (EMR).

• Coordinate supportive services, such as transportation, for patients with complex needs.

• Promote patient engagement and shared decision-making through the development of SMART goals.

• Use patient-centered approaches to build rapport and support patients in addressing health-related social needs.

• Refer patients to community and social support services to reduce access barriers, strengthen self-management skills, and support improved health outcomes.

• Visit or communicate with community and clinical resource organizations as part of their role to better connect patients to resources and help patients understand the program, how to access it, and the staff who work there.

• Follow all protocols and procedures required by funders and by La Clinica del Pueblo regarding care coordination duties and responsibilities.

• Demonstrate professional, effective, and respectful communication skills, including written, verbal, and nonverbal.

• Maintain a positive attitude and provide respectful, professional customer service.

• Uphold patient confidentiality, respect patient rights, and comply with HIPAA regulations at all times.

• Act as a patient advocate by responding with empathy and respect to patient and family concerns and identifying opportunities to improve care experiences.

• Engage in ongoing learning to enhance professional skills and improve quality of care.

• Maintain complete, accurate, and confidential medical records in accordance with organizational standards.
  

Increase visibility of the Case Manager as part of the primary care team.

• Participate in daily huddles and team meetings to provide case updates, share community resources, and highlight patient experiences.

• Use PRAPARE as a teaching tool during huddles and provider meetings to explain how social needs screening supports patient care.

• Maintain physical presence with the primary care team to support warm handoffs and identify patients needing additional services.

• Maintain approachability and visibility when not meeting with patients

• Support program manager by participating in La Clínica’s Health Equity Hub Workgroup every month to strengthen and vet external partnerships in clinical, food, legal services, housing, employment, and transportation.

• Follow all protocols and procedures required by funders and by La Clinica del Pueblo.

• Acknowledge patients’ rights on confidentiality issues, always maintain patient confidentiality, and follow HIPAA guidelines and regulations.

• Attend required internal and external program meetings.

• Complete monthly reports assigned.

• Meet with supervisor as required.

• Perform other duties as assigned by the supervisor.

Supervisory Responsibilities: N/A
Physical Requirements: Prolonged periods of sitting at a desk and working on a computer