Careers

This position revolves around clinical case management services aimed at enhancing patient-centered care and maximizing outcomes across the patient care continuum. Case management services include patient advocacy, monitoring patient care to ensure progress toward desired outcome, addressing patient and family needs, resolving obstacles to effective care, and together with the behavioral health team, planning for patient treatment and follow-up care.

• Provide advocacy, education and ongoing follow-up as needed to ensure access to needed healthcare services.
• Link eligible patients with free or reduced cost primary and specialty care services.
• Conduct outreach at community sites to promote the local uninsured access to and use of available healthcare services.

Must demonstrate the Rural Health Group Core Competencies, which include:

1. Good Judgment
2. Communication/Customer Service/Teamwork
3. Passion
4. Honesty
5. Responsibility
6. Job-Specific Skill Set - including knowledge, skills, and ability to fulfill the responsibilities of a Case Manager.

ROLES AND RESPONSIBILITIES:

• Participate actively in team-based care.
• Coordinates case management process from patient's entry into the healthcare system to specialty care to hospital admission to follow-up care. Coordinates care and resources with physicians, behavioral health specialists, case managers and other team members to achieve optimal patient outcomes.
• Complete initial patient/family assessments and develop problem lists.
• Identifies patients who are suitable for case management intervention based on criteria such as case complexity, frequency of appointments or hospital utilization (emergency room usage and general admits). Seeks authorization for case management services from patients and/or families.
• Perform occasional home visits and phone follow up as indicated.
• Collaborate with patients, physicians, community health centers and other providers to develop a comprehensive plan of care.
• Effectively communicate care plans and other patient-related activities both verbally and in writing to appropriate personnel and agencies.
• Utilize clinical skills and assessments to work autonomously in the community settings. Demonstrate the ability to use teaching, learning and counseling skills.
• Act as a patient advocate for the development of community resources.
• Consult others to identify potential community resources for resolving patient health, psychosocial, or financial problems.
• Function as a liaison to external agencies.
• Collaborate effectively with departmental/program staff to achieve goals and objectives.
• Ensure collection of data for outcomes, reports and other studies as requested.
• Provide information for maintenance of case management patient database.
• Support efforts to implement disease management model.
• Demonstrate effective interpersonal communication skills.
• Facilitate productive meetings with interdisciplinary team members from across the system.
• Participate in financial planning for specialty care.
• Maintain and advance knowledge and skills in area of specialization.
• Encourage clinical problem identification and resolution activities.
• Identify, address, and report quality issues identified through data sources.

Requirements:

• Bachelor's or Master's degree preferred in Social Work or related field. Candidate most welcome would be one who is interested in becoming an LCSW.
• One year of experience in a clinically related area; and demonstrated team stewardship, relationship building, critical analysis
• Knowledge of funding resources and clinical standards and outcomes
• Strong computer skills, including proficiency with Microsoft Office; EHR experience is a plus
• Valid driver’s license and reliable transportation
• Bilingual (Spanish) is a plus, but not required; applicants who may serve in an interpreting capacity will be required to take a language assessment

Competent in the following:

• Organization skills
• Evaluation skills
• Change management
• Self-direction

Demonstrates:

• Strong verbal and written communication / interpersonal skills; proficient teaching skills
• Effective decision-making and problem-solving skills
• Flexibility and assertiveness
• Ability to use good judgment
• Ability to work effectively with others
• Creativity and attention to detail in the production of materials
• Timely completion of documentation
• Understanding of patient-centered care
• Appropriate awareness of personal and professional boundaries with staff and patients

EOE. Federal and State Criminal Background Checks and Drug Screen required for all positions. The influenza vaccine is a condition of employment.

E-Verify Notice: After accepting employment, new hires are required to complete an I-9 form and present documentation of their identity and eligibility to work in the United States.