BILINGUAL SOCIAL SERVICES NURSE CASE MANAGER

RAVENSWOOD FAMILY HEALTH CENTER•East Palo Alto, CA

1d•$40 - $55

About The Position

The Social Services Nurse Case Manager, under the administrative direction of the Social Services Manager and the Integrative Behavioral Health and Social Services Director, is a key staff member that will provide vulnerable patients and their families with the resource support needed to achieve their health care goals in outpatient and community settings. These services may include assistance to access food, shelter, housing, clothing, legal assistance, durable medical equipment, in-home support, transportation, interpretation, case management home care, clarification of coverages for services outside RFHN, and other community supports as requested and referred by RFHN and community agency providers. Bilingual Spanish/English proficiency is required. This position reports to the Social Services Manager and works closely with the Senior Manager of Social Services, Social Services Care Coordinators, IBHS staff, the Enhanced Care Management (ECM), Medicated Assisted Treatment (MAT) Teams, and the Health Care for the Homeless (HCH) Manager.

Requirements

Bachelor’s degree in Nursing from an accredited college, plus two years of increasing case management responsibilities.
Bilingual English/Spanish proficiency required.
Knowledge of individual and group behavior, human growth and development, and family relationships.
Knowledge of public health principles, including the social determinants of health.
Knowledge of community resources, social service agencies and functions of those agencies.
Proactive approach to daily tasks.
Proficient in data entry and computer software; experience with Epic software a plus.
Able to travel to all clinic locations, patient’s residence and/or other community setting to meet patient.
California Drivers’ License and automobile insurance required.
Able to function independently and consult with a clinical provider when necessary.
Excellent verbal and written communication skills and demonstrated ability to adapt communication style to audience; strong skills to motivate, inspire and persuade.
Excellent interpersonal skills with the ability to foster trust and respect among patients from diverse language and cultural backgrounds. Ability to counsel clients of all ages and problems.
Communicates with warmth and confidence.
Able to work with protected health information and maintain absolute confidentiality and privacy in accordance with HIPAA regulations.
Ability to organize multiple tasks and manage competing priorities.

Nice To Haves

Up to date with COVID-19 vaccines per current CDC guidelines strongly recommended.

Responsibilities

Collaborates with ECM, MAT, HCH, IBHS, and other RFHN care teams to develop appropriate care management plans based on patients’ and their families’ medical, social and mental health needs.
Provides a range of behavioral interventions, including but not limited to, crisis intervention and supportive counseling, identification of present problem, performing triage services, skills building, supportive sessions, psychosocial assessments, case management, education for different behavioral issues and social drivers of health, behavioral health screens, and follow-up sessions for patients as needed.
Provides face-to-face follow-up with patients and providers as needed.
Provides interventions from a strength-based and an empowerment perspective.
Provides clinical warm hand-offs as needed for the different medical providers and staff.
Works closely with medical providers and care teams to intervene with patients needing immediate consultation.
Provides collaborative case management that includes contacting other mental health providers, medical practitioners, school personnel, and social services; communicating with patients to provide them with appropriate referral, follow-up, or other information; ensuring that patient consent forms are complete; and monitoring treatment goals.
Involves patients and families in the assessment, determination, and implementation of social work care management plans.
Attends, participates in, and reports status of program activities at 1:1 meeting with supervisor and other meetings as requested by supervisor.
Brings urgent/critical issues to supervisor’s attention with a sense of urgency.
Documents comprehensive progress notes in a timely manner in the patient’s health care record.
Maintains compliance with all applicable county, state and federal laws and regulations, funder and program requirements, including maintaining timely accurate documentation in EPIC and Health Plan electronic systems.
Other duties as assigned and requested.