Medical Case Manager

TRILLIUM HEALTH INC•Rochester, NY

About The Position

The Case Manager provides proactive, patient-centered disease‑ or condition‑specific care coordination for attributed patient/client panels and individuals with complex medical, behavioral health, and social needs. This role supports team‑based primary care, quality improvement initiatives, data-driven population health processes, and assists leadership with onboarding and mentorship of Community Health Workers. The Care Manager is embedded within an assigned service area to facilitate direct access to services, support chronic disease management, and build community partnerships. Operating with independence, this role requires strong engagement, assessment, and care coordination skills to ensure patients/clients receive comprehensive, culturally appropriate support.

Requirements

Bachelor’s degree with two years of experience in health, human services, or education and one year of qualifying case management or casework experience with individuals with chronic illness, mental illness, homelessness, or chemical dependency;
High School Diploma/GED with five years of qualifying experience.
Strong patient/client engagement and problem‑solving skills.
Understanding of chronic conditions and social drivers of health.
Ability to multitask and prioritize in a fast‑paced environment.
Experience with motivational interviewing and trauma‑informed care.
Strong interpersonal skills to build internal and external partnerships.

Nice To Haves

Experience working with high‑risk or vulnerable populations.
Experience in an FQHC, patient-centered medical home, or value‑based care model.
Ability to interpret data reports or performance dashboards.
Bilingual skills highly preferred.

Responsibilities

Support disease-specific, condition-specific, and health-related social needs within a multidisciplinary team.
Assist patients/clients in navigating insurance, completing paperwork, obtaining durable medical equipment, and accessing supportive services.
Provide proactive outreach for preventive care, chronic disease follow-up, and continued engagement.
Conduct assessments related to medical, behavioral health, and social needs, including SDOH.
Coordinate and track referrals across specialties, imaging, behavioral health, dental, and community partners.
Facilitate access to transportation, food resources, housing supports, and additional social services.
Complete intake, assessment, and reassessment processes for internal grant services per required standards.
Facilitate case conferences and ensure continuous communication with patient/client providers and support teams.
Document care coordination activities in the EHR accurately and timely.
Utilize reports/tools to identify rising‑risk or high‑risk patients/clients.
Support population health process improvement.
Contribute to achievement of disease‑specific quality measures (e.g., cardiovascular, hypertension, diabetes, HIV, Hepatitis C).
Lead or participate in targeted outreach initiatives.
Conduct pre‑visit planning and outreach for appointment reminders and follow-up needs.
Participate in post‑visit care planning to address health and safety requirements.
Provide culturally appropriate disease management education and self‑management support.
Assist patients/clients with creating achievable health goals, including those related to social drivers of health.
Conduct retention outreach for individuals considered “lost to care.”
Serve as a resource and mentor to Community Health Workers.
Support onboarding, training, and case review discussions.
Offer workflow feedback and participate in care management quality improvement activities.