SACRAMENTO NATIVE AMERICAN HEALTH CENTER INC·Sacramento, California
Provide comprehensive case management and care coordination for patients with complex physical, behavioral, and social needs. Collaborate with healthcare providers and community agencies to develop individualized care plans and ensure seamless service delivery.
The Medical Case Manager (CMC) provides comprehensive case management and care coordination for patients with complex physical, behavioral, dental, and social needs. While primarily managing an assigned panel, the support provided extends to all patients as necessary. The CMC is responsible for client interviews, data collection, confidential record-keeping, client recruitment, and assisting with establishing care at SNAHC. This role involves close collaboration with program stakeholders, healthcare providers, healthcare payors, social services agencies, and other community-based organizations to ensure seamless coordination of services and patient support. Essential Functions: Coordinate referrals to appropriate programs based on eligibility criteria, patient needs, and provider assignment. Assists with durable medical equipment (DME) referrals for the medical department. Ensure productivity goals are met weekly. Assesses patients’ health status, regional resource utilization, and barriers to care to develop individualized care plans with short- and long-term goals. Maintains ongoing and effective engagement with assigned patients through in-person meetings, text/telephone communication, and community outreach. Provides in-person support to patients in waiting rooms and during appointments Ensure all patients have accurate and up-to-date shared care plans. Connects clients to a variety of services and resources to address their comprehensive needs. Participate in medical team huddles to enhance communication between the care team, partner outreach, and housing agencies. Maintains clear and timely documentation of all patient interactions, care plans, and outcomes in accordance with program requirements. Participates in care coordination meetings with dental and behavioral health departments for internal case conferences. Track patient panels in the electronic Population Health Management System. Collaborate with patients to follow organizational guidelines through non-judgmental and caring interactions. Support quality improvement initiatives in accordance with the organization's mission and strategic goals, federal and state laws and regulations, and accreditation standards. Comply with all state and federal laws and regulations, including HIPAA, sexual harassment, scope of practice, OSHA, etc. Participate in internal quality improvement teams. Works with team members proactively to drive quality improvement initiatives in accordance with the mission and strategic goals for the organization, federal and state laws and regulations, and accreditation standards. May be required to travel between sites for coverage and/or meetings. Other duties as assigned. Skills and Abilities: Excellent computer skills, preferably with Windows, including Microsoft Office Suite Excellent telephone and communication skills Must possess excellent organizational, writing, and verbal skills. Ability to work independently, set priorities, and work well under pressure. Ability to maintain a high degree of confidentiality Ability to demonstrate superior professionalism when dealing with patients, subordinates, colleagues, community members and vendors. Ability to collaborate and convene across sectors and organizational levels.
Bachelor’s Degree or equivalent work experience in a Health, Social Services, or related field. Knowledge, understanding, and use of Electronic Health/Administrative Records Experience in an FQHC setting Knowledge of and experience with Social Determinants of Health Knowledge of traditional, cultural, and spiritual practices of the diverse AI/AN community, as well as the ability to work with other racially, culturally, ethnically, and financially diverse populations. Bilingual Please Note: This position may be grant funded. Continued employment is contingent upon renewed or additional funding and may be discontinued at the close of the grant cycle. Grant funding for any position does not impart any contractual right, either expressed or implied, to remain in Sacramento Native American Health Center, Inc.’s employment for a specific period of time. Grant funding does not affect the Sacramento Native American Health Center, Inc.’s status as an “at will” employer.
Requires at least two years of experience in health or social services and proficiency with Electronic Health Records. Preferred candidates hold a bachelor's degree and have experience working with diverse, low-income, or homeless populations in an FQHC setting.
Market context
In California, behavioral-health roles tied to substance use disorder counseling and case management are typically supported by ongoing community and treatment-program demand. These positions are competitive because employers often look for a high school diploma, at least 2 years of SUD counseling or case management experience, and current Registered or Certified Drug and Alcohol Counselor status. Review the AI-summarized requirements and benefits here to quickly compare fit and note that professional development and paid continuing education are listed as benefits.
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