Case Manager

Position Purpose:

The Case Manager is a key member of the interdisciplinary care team and plays a critical role in supporting patients with complex medical and social needs. Under the supervision of the Community Health Supervisor, this position provides episodic case management services and comprehensive care coordination designed to improve health outcomes, reduce barriers to care, and support safe transitions across healthcare settings.

Basic Qualifications

Education and Experience:

• Bachelor’s degree in psychology, public health, social work, human services, or related field required.

• Minimum of 2 years of experience in healthcare, behavioral health, or community-based case management preferred.
• Experience working with high-risk or vulnerable populations strongly preferred.

Knowledge, Skills, and Abilities:

• Strong understanding of medical terminology and chronic disease management principles.

• Experience with Electronic Medical Records and care coordination documentation.
• Demonstrated ability to manage a complex caseload with competing priorities.
• Excellent communication, problem-solving, and advocacy skills.
• Ability to exercise sound judgment and maintain professional boundaries

Licensure/Certification:

• Relevant certifications in care coordination, community health work, or case management are a plus.
• CPR Certification

Essential Duties:

1. Episodic Case Management

• Conduct brief assessments of patient case management needs.
• Assist patients with applications for public benefits, housing support, transportation services and other community resources.
• Facilitate referrals and ensure closed-loop communication with community partners.
• Advocate on behalf of patients within healthcare, behavioral health, and social service systems.
• Provide short-term case management interventions to address immediate barriers to care.
• Maintain current knowledge of local, state, and federal community resources and eligibility requirements.

2. Comprehensive Care Coordination

• Manage a caseload of high-risk and medically complex patients.
• Develop, implement, and monitor individualized care plans in collaboration with patients, families, providers, and community partners.
• Conduct post-discharge outreach and follow-up to reduce avoidable emergency department utilization and hospital readmissions.
• Proactively address barriers to care including housing instability, food insecurity, transportation challenges and access to specialty services.
• Provide ongoing case management including follow-up, reassessment, and adjustment of care plans based on patient progress.

3. Interdisciplinary Collaboration

• Serve as an active participant in multidisciplinary care team meetings.
• Communicate effectively and professionally with all CHC staff and external agencies.
• Support safe and appropriate patient de-escalation when needed.

4. Population Health & Quality Improvement

• Support organizational population health initiatives including chronic disease management and care gap closure.
• Assist in identifying patients who would benefit from services through risk stratification tools, provider referrals, hospitalization reports, and quality data.
• Participate in quality improvement initiatives aimed at improving care coordination processes and patient outcomes.
• Track and report patient outcomes as required.

5. Organizational & Professional Expectations

• Deliver culturally responsive, trauma-informed, patient-centered care.
• Document all patient encounters, assessments, care plans, interventions, and outcomes in the electronic medical record in accordance with organizational and regulatory standards.
• Maintain current knowledge of healthcare systems, community resources, and organizational policies.
• Contribute to a collaborative, efficient, and mission-driven work environment.

 Non-Essential Duties:

Other duties as assigned.

Physical Demands Working Conditions:

• Ability to lift up to 25lbs.
• Work is performed in an indoor, controlled environment workspace.
• Exposure to infectious disease by way of patient contact.