Case Manager II - Tailored Care Management (TCM) - Carolina Family Patient Support Services

Carolina Family Health Centers•Wilson, NC

63d•Onsite

About The Position

Carolina Family Health Centers, Inc. is a nonprofit, federally qualified health center (FQHC) dedicated to providing accessible and affordable healthcare to the community. We believe everyone deserves quality health care, regardless of their ability to pay or insurance status. Our integrated model offers primary medical care, behavioral health, pharmacy, and dental services. The Case Manager II in Tailored Care Management is a vital member of the Carolina Family Patient Services team, working directly with patients to provide tailored care management services to a specified panel of patients within the clinical setting. This position reports to the Tailored Care Management Program Manager.

Requirements

Associate's, Bachelor's, or Master's Degree in Nursing with applicable post-graduate experience with the population being served (four years of full-time applicable post-graduate experience required for nursing degrees).
Alternatively, must be a Licensed Clinical Social Worker or Licensed Clinical Addictions Specialist.
Effective communication and interpersonal skills.
Must demonstrate the skills and judgment necessary to provide direct care to patients under the direct supervision of the Supervising Tailored Care Manager.
Strong computer skills and working knowledge of the windows-based environment and Electronic Health Record (EHR) experience.
BLS Certification
North Carolina Driver’s License

Responsibilities

Provide behavioral and medical care management to low, medium, and high-risk patients.
Perform annual comprehensive assessments to evaluate patients behavioral and medical healthcare needs and social determinants of health to develop individualized and person-centered care plans using a collaborative approach including patient and family participation, where possible.
Collaborate with community agencies for referral resources to assist patients and utilize NCCARE360.
Establish and document a care plan with the patient and/or family members.
Update and document care plans as the patients; needs change and/or to address gaps in care.
Identify patients with recent emergency department visits or hospital admissions, and assist with transitions back to primary care providers and behavioral health providers.
Work toward improving overall quality metrics rating by bringing members into compliance and closing gaps in care.
Performs other duties as assigned.