Medical Case Manager

Job Title: Medical Case Manager
Department: Medical
Reports To: Clinic Director
Status: Full-time, Non-Exempt

Position Summary

The Medical Case Manager provides comprehensive care coordination and support services to patients with complex medical needs. This role focuses on patient advocacy, resource linkage, chronic disease management, and integrated care planning to ensure improved health outcomes. The Medical Case Manager works closely with medical providers, behavioral health professionals, and community partners to address barriers to care and promote holistic wellness in alignment with The NATIVE Project’s mission and values.

Essential Duties & Responsibilities

• Conduct initial and ongoing assessments of patients’ medical, psychosocial, and environmental needs.
• Develop individualized care plans in coordination with medical providers and other interdisciplinary team members.
• Monitor patient progress toward care plan goals and adjust interventions as needed.
• Support patients in accessing healthcare services, medication adherence, diagnostic testing, specialty referrals, and preventive care.
• Provide education to patients and families on chronic conditions, treatment plans, and community resources.
• Coordinate referrals to internal services (Behavioral Health, Dental, Wellness/Prevention) and external agencies.
• Collaborate with hospital discharge planners, home health agencies, and other case managers to ensure continuity of care.
• Participate in quality improvement initiatives and case reviews to enhance patient care.
• Document all case management activities accurately and timely in the electronic health record (EHR).
• Monitor outcomes and collaborate with the Quality Improvement (QI) team to ensure program effectiveness and compliance with national standards, such as GPRA, UDS, and NCQA.

Qualifications

• Education & Certification: Bachelor’s degree in Nursing, Social Work, Public Health, or a related field required. RN, LPN, or L/MSW preferred.
• Experience: Minimum of 2 years’ experience in case management, care coordination, or medical social work. Experience in a community health or tribal health setting preferred.
• Skills & Competencies:
  • Strong understanding of health disparities and barriers to care in underserved populations.
  • Knowledge of chronic disease management, social determinants of health, and trauma-informed care.
  • Excellent interpersonal, communication, and documentation skills.
  • Proficient in EHR systems and Microsoft Office Suite.
  • Ability to work independently and as part of a multidisciplinary team.
  • Cultural competency and sensitivity to Native American values, traditions, and community needs.

Working Conditions

• Standard clinical office environment with occasional home visits or community-based outreach.
• Must be able to lift 20 pounds, sit or stand for extended periods, and use a computer for documentation.
• May require flexible hours depending on patient and program needs.

Equal Employment Opportunity (EEO) Statement

The NATIVE Project is an equal-opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.