Case Manager, Medical

SACRAMENTO NATIVE AMERICAN HEALTH CENTER INC•Sacramento, CA

5d•$25 - $27

About The Position

The Medical Case Manager (CMC) provides comprehensive case management and care coordination for patients with complex physical, behavioral, dental, and social needs. While primarily managing an assigned panel, the support provided extends to all patients as necessary. The CMC is responsible for referrals, client interviews, data collection, confidential record-keeping, client recruitment, and assisting with establishing care at SNAHC. This role involves close collaboration with program stakeholders, healthcare providers, healthcare payors, social services agencies, and other community-based organizations to ensure seamless coordination of services and patient support.

Requirements

Excellent computer skills, preferably with Windows, including Microsoft Office Suite
Excellent telephone and communication skills
Must possess excellent organizational, writing, and verbal skills.
Ability to work independently, set priorities, and work well under pressure.
Ability to maintain a high degree of confidentiality
Ability to demonstrate superior professionalism when dealing with patients, subordinates, colleagues, community members and vendors.
Ability to collaborate and convene across sectors and organizational levels.
Two years or more in a Health, Social Services, or related field
Experience working in an Electronic Health Record (EHR) environment.
Experience and knowledge of the culture and environmental issues significant to homeless individuals, low-income families, mental health patients, and individuals involved in the criminal justice system.
Experience with interventions such as motivational interviewing, de-escalation, harm reduction, and trauma-informed care in a diverse clinical setting.

Nice To Haves

Bachelor’s Degree or equivalent work experience in a Health, Social Services, or related field.
Knowledge, understanding, and use of Electronic Health/Administrative Records, Resource Patient Management Systems NextGen.
Experience in an FQHC setting
Knowledge of and experience with Social Determinants of Health
Knowledge of traditional, cultural, and spiritual practices of the diverse AI/AN community, as well as the ability to work with other racially, culturally, ethnically, and financially diverse populations.
Bilingual

Responsibilities

Coordinate referrals to appropriate programs based on eligibility criteria, patient needs, and provider assignment.
Assists with durable medical equipment (DME) referrals for the medical department.
Ensures productivity goals are met weekly.
Assesses patients’ health status, regional resource utilization, and barriers to care to develop individualized care plans with short- and long-term goals.
Maintains ongoing and effective engagement with assigned patients through in-person meetings, text/telephone communication, and community outreach.
Provides in-person support to patients in waiting rooms and during appointments
Ensure all patients have accurate and up-to-date shared care plans.
Connects clients to a variety of services and resources to address their comprehensive needs.
Participate in medical team huddles to enhance communication between the care team, partner outreach, and housing agencies.
Maintains clear and timely documentation of all patient interactions, care plans, and outcomes in accordance with program requirements.
Participates in care coordination meetings with dental and behavioral health departments for internal case conferences.
Track patient panels in the electronic Population Health Management System (i.e., i2i).
Collaborate with patients to follow organizational guidelines through non-judgmental and caring interactions.
Support quality improvement initiatives in accordance with the organization's mission and strategic goals, federal and state laws and regulations, and accreditation standards.
Comply with all state and federal laws and regulations, including HIPAA, sexual harassment, scope of practice, OSHA, etc.
May be required to travel between sites for coverage and/or meetings.
Other duties as assigned.