Under the direction of the Clinic Manager, the Case Manager works as part of the Enhanced Care Management (ECM) team and Primary Care Provider (PCP) care team to provide high quality, efficient and service oriented patient/member care while demonstrating the health center’s core values. The Case Manager is responsible for all phases of case management. The Case Manager uses an integrated (medical/behavioral health) case management program and a collaborative relationship-based approach, to assist poly‑chronic and high‑risk patients to improve health outcomes. Case Managers use a comprehensive, whole person health assessment of the patient’s current situation and status, identifies actionable barriers and obtainable goals to achieve optimal self‑care management and monitors the patient’s progress towards their goals. Utilizing Camino’s electronic health record system, the Case Manager is responsible for capturing, monitoring and working all case management referrals requested by the providers. The Case Manager works closely with ECM and their care team to organize activities necessary to successfully meet requirements established by managed care plans, HEDIS clinical quality measures and FQHC clinical performance measures. Ensure that the core values of Camino Health Center – Service, Dignity, Justice and Excellence are carried out within daily tasks. Essential Values‑Based Competencies Dignity: Demonstrates competence in communication and interpersonal relations Excellence: Demonstrates competence in continuous improvement, continuous learning, and teamwork/collaboration Service: Demonstrates competence in customer/patient focus, adaptability, and shaping change Justice: Demonstrates competence in community orientation, stewardship, and strategic planning and action Patient Relations Work diligently, cooperatively, and effectively with patients, medical providers, health center staff and community stakeholders in all aspects of patient care and case management. Provide positive, supportive and caring behavior in all communications to patients, community stakeholders and staff. Maintain patient confidentiality and HIPAA practices at all times. Outreach and Engagement Provide a patient orientation to those that are referred to case management, explain what the benefits are and how it will support them in addressing their health care needs. Identify specific times to connect with the patients, to inquire or provide needed updates, in person or over the phone. Communicate and deliver easy to read information about health and wellness, referrals to specialists, and other community resources that may be beneficial to the patient. Share socioeconomic resources that may benefit the member and address important items such as food insecurity, sheltering needs, etc. Identify opportunities to schedule in clinic appointments to address various health needs/screenings; arrange transportation as needed to and from the clinic. Case Management Works closely with the Primary Care Provider (PCP) teams, Enhanced Care Management (ECM) team, Behavioral Health Specialists (BHS) and Referral Specialists. Engage patients with medical, mental health and/or substance utilization disorders in health support services utilizing evidence‑based engagement skills. Conduct initial holistic health assessment of patient’s current conditions, situation and needs and performs ongoing evaluations. Assessment will include evaluating the patient’s social determinants of health (SDOH) and cultural influences on health care practices. Collaborate with the patient, caregivers, and providers to develop a patient‑centric case management plan that addresses barriers and promotes improved health outcomes. Monitor and evaluate the effectiveness of the patient’s care management plan and continuously update it to ensure goals are progressing and remain pertinent, adjust goals as needed, and identify/address barriers to completing goals. Facilitate communication and coordination among the health care team to minimize fragmentation, eliminate duplication, and maximize delivery of appropriate care. Provide interventions focused on removing the patient’s barriers to health improvement, promoting positive behavior change using Motivational Interviewing techniques, and addressing the caregiver’s/family member’s needs in order to stabilize the patient’s natural support system. Work in the moment to address arising issues brought forth by the providers, staff, caregivers, and family members; must leverage strong problem‑solving skills to overcome challenges in the patient’s case management. Use the electronic medical record (EMR) system to accurately track the progression of the patient’s case management. Maintain concise, accurate and timely documentation that supports effective, efficient management of the member and that meets accreditation, contractual and legal requirements. Participate in weekly case review to discuss patient challenges and seek input from peers and providers on potential solutions to current issues/barriers to care. Engage in quality improvement initiatives and projects, such as identifying and addressing gaps, and developing/testing new practices to improve case management outcomes. Model the highest ethical behavior in relationships with co‑workers, supervisors, members, providers, and colleagues in the community. Participate in all appropriate staff meetings or other activities as needed. Additional Responsibilities Performs other duties as assigned by supervisor. Minimum Position Qualifications Education: High school Diploma or GED required. Experience / Training: Two years of experience working in a healthcare setting is required. Experience working in case management within the medical office and/or behavioral health; ideally in environments with individuals who struggle with chronic illness, substance use disorders and mental health issues. License / Certification: BLS certification required. Preferred Position Qualifications Experience / Training: Bachelor of Science in health or human services related field; other undergraduate degrees will be considered. Licensed Vocational Nurse (LVN) with case management experience. Enhanced Care Management (ECM) experience. Must have reliable transportation to report for shifts. #J-18808-Ljbffr