SUMMARY: Provide ongoing, extended case management as assigned. Coordinate care and referrals to wrap around services that support clinical care. This includes enrollment into insurance and benefit programs for which clients are eligible: transportation, housing, food, behavioral health specialty care and substance abuse treatment. In addition, making proactive contacts to improve patient outcomes and build relationships with health and social services agencies in the community. ESSENTIAL DUTIES AND RESPONSIBILITIES: Work with crisis intervention, complex and chronic mental illness, and substance abuse in a multi-disciplinary team setting. Work with underserved and/or transient populations. Work with patients who have co-occurring mental health, substance abuse, and physical health problems. Knowledge of general medical practice models and processes such as office procedures, medical records, health insurance, etc. Knowledge of clinical data collection and analysis strategies needs assessments and program development. Skilled in data collection, tracking, and monitoring. Effectively collaborate with other health professionals in a team setting, and work to develop procedures to promote integrated behavioral health access and care. Able to multi-task and complete a variety of tasks each day (e.g., phone calls, outreach, referrals, EMR documentation, etc.) Other duties as assigned. OTHER ESSENTIAL DUTIES and RESPONSIBILITIES: Grace Health recognizes that managing patient care is a team effort that involves clinical and non-clinical staff. All employees must embrace a team-based approach to patient care and understand that each role is important to our success. Team members must demonstrate excellent team communication and coordination to provide quality patient care. Care coordination includes communicating with community organizations, health plans, facilities, and specialists. Care team members understand and embrace the concept of population management and proactively address the needs of patients and families served by this practice. Team members must demonstrate skill and knowledge related to effective communication with vulnerable patient populations. Team members must participate in Continuous Quality Improvement activities within the organization to ensure patients receive high quality care. All team members will be involved in the process of improving quality outcomes. Team members will participate in the review and evaluation processes of practice performance and help to identify opportunities for improvement. Team members will participate in Grace Health's advocacy program . GENERAL DUTIES: Follow policies and procedures of the office, including administrative, clinical, quality assurance, and personnel. Maintain good attendance (daily, meetings, and other assignment tasks). Maintain timely documentation of all work assignments. Maintain patient confidentiality. Routinely keep supervisor informed about attendance and job assignments. Flexible in being able to multitask. Work effectively and at an efficient pace. Work cooperatively with providers, administration, and peers.
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Job Type
Full-time
Number of Employees
1-10 employees