Position Summary
Assists individuals and groups with personal, social, emotional and environmental difficulties which predispose illness or interfere with obtaining maximum benefits from medical care. Staff supports providers through an integrated approach to care management and community outreach.
Develops individualized plans of care with targeted interventions; monitors patients and family responses to the plan of care and adjust as needed
Specific Focus is directed to the Healthcare for the Homeless, Prison Re-entry and those with Substance Use Disorders. Provides ongoing case management services for those in need of this level of support.
Duties and Responsibilities
- Performs assessments and provide case management for homeless individuals seeking services at the Family Health Center
- Coordinates with community agencies to assure that linking, monitoring and coordinating occurs in regards to preventative services for individuals served.
- Reaches out to locate individuals to help schedule their services and appointments both telephonically
- Communicates with health care team members and agencies to obtain pertinent information to be utilized in evaluating patient needs.
- Provides patients with self-management tools and support to enhance their ability for self-care
- Maintains required documentation for all case management activities.
- Coordinate and provide early intervention services for those exhibiting signs of substance use disorders who may not be amenable treatment services or who do not meet diagnostic criteria.
- Prepares case histories for use in diagnosis and treatment. Develops intervention and treatment plans which include an evaluation of family support, patient strengths, and level of risks. Make referrals as needed based on the evaluations.
- Works in close collaboration with physicians and other health care personnel in patient evaluation and treatment to further their understanding of significant social and emotional factors underlying patient's health problem.
- Identifies patients at risk for development for further issues and locates additional Family Health Center or community services best designed to meet their needs.
- Develops comprehensive person-centered treatment plans in conjunction with patients to meet their social, emotional and behavioral needs. May assist in obtaining authorizing for these additional services.
- Helps patient(s) through individual or group sessions to understand, accept, and follow medical recommendations. Follows through on treatment plan in patient's records.
- Participates as member of multi-disciplinary team as needed
- Maintains required case documentation and records delivered services in an accurate and timely manner as required by regulating entities, accreditation organizations, and management.
- Attends required in-service, departmental and organizational meetings. Participates in clinical review of cases.
- Reviews Current literature on engagement and communication strategies and incorporates best practices into the clinical setting
- Participates in community collaborative as necessary.
Competencies
- Collaborative
- Displays willingness to make decisions, resolve conflict and delegate work assignments in a timely manner
- Adapts to change, takes responsibility for own actions to advance team goals
- Speaks and writes clearly and persuasively in formal and informal presentations
- Actively participates in meetings and uses listening skills to keep an open mind
- Solicits input from appropriate stakeholders, explains reasoning for decisions and uses strong interpersonal skills to communicate and influence others
- Gives recognition to others for results
- Solid Character
- Balances team and individual responsibilities while assessing own strengths and weaknesses
- Exhibits objectivity and openness to others' views
- Welcomes feedback, builds positive team spirit, supports all team members
- Develops alternative solutions, supports and share expertise with other team members while building positive morale
- Demonstrates knowledge of company policies and treats people with respect
- Works ethically and with integrity, upholds organizational values
- Keeps commitments, shows respect and sensitivity for cultural differences
- Educates others on the value of diversity, promotes a positive work environment where all feel free to contribute
- Organizational Support
- Completes administrative task correctly and on time, and develops strategies to achieve organizational goals and values
- Supports affirmative action and respect diversity, understands organization's strengths and weaknesses, analyzes market and competition, and identifies external threats and opportunities while adapting strategy to changing conditions
- Prioritizes and plans work activities while understanding business implications of decisions
- Demonstrates accuracy and thoroughness within approved budget and displays original thinking and creativity
- Displays knowledge of market and competition that aligns with strategic goals
- Meets challenges with resourcefulness, generates suggestions for improving work, develops innovative approaches and ideas
- Leadership
- Displays passion and optimism while exhibiting confidence in self and others
- Inspires respect and trust while motivating others to perform well and influencing actions and opinions of others
- Coordinates projects, develops workable implementation plans, includes staff in planning, decision-making, and process improvement
- Communicates and completes changes and progress of projects on time and on budget while managing project team activities to overcome resistance
- Makes self-available to staff, provides regular performance feedback
- Develops individual team member skills and encourages growth Safety and Security
- Promotes safety precautions and security measures to ensure the safety of both staff and patients
- Adheres to data security guidelines, including appropriate use of EMR systems and IT resources
Typical working conditions
- The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- The noise level in the work environment is usually moderate noise. May be exposed to communicable diseases or blood borne pathogens.
Typical physical demands
While performing the duties of this job, the employee must be able to communicate and collaborate effectively with patients, staff, providers, and others in person, by telephone, email, video conferencing, or other electronic means, with or without reasonable accommodation.
The employee is frequently required to sit or stand.
The employee regularly uses hands to operate equipment, handle objects, and perform job-related tasks.
The employee must occasionally lift, carry, push, or pull up to 25 pounds, with or without reasonable accommodation.
Must be able to accurately read and interpret printed and electronic information, observe patients, equipment, and the work environment as necessary to perform essential job duties, and perform tasks requiring visual attention, with or without reasonable accommodation.
Qualifications
- Prefer the ability to speak both English and Spanish.
- Knowledge of medical terminology preferred but not required.
- Have the ability to effectively communicate with all people regardless of socioeconomic status, ethnicity, and education level.
- Professional phone skills required.
- Must be familiar with a variety agency programs that serve our client population.
- To perform this job successfully, an individual should have knowledge of Microsoft Office utilizing Excel Spreadsheet software and Word processing software.
- Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving multiple variables in standardized situations.
Education/Experience/Certifications/Licenses
- Requires Bachelors of Social Work or other Human Service Field and minimum of two plus year's related experience and/or training; or equivalent combination of education and experience. Master's Degree Preferred.
- Must have experience with mental health and substance abuse.
- Knowledge of Medicaid is a plus.
Family Health Center hos the right to modify the duties and functions of the job description based on the needs of the organization.
