Case Manager CCH

Tulsa Health Department•James O Goodwin Health Center Tulsa OK, OK

12d•Hybrid

About The Position

The Center for Community Health (CCH) aims to improve health disparities in Tulsa, reduce hospital readmissions and inappropriate ER usage, and increase primary care utilization to enhance patient health outcomes within the Saint Francis Health System (SFHS). The Case Manager (CM) will serve as a crucial link between CCH clients and community health services. This role involves coordinating referrals to community agencies for ongoing support, treatment, and continuity of care, as well as maintaining electronic documentation of client interactions. CMs will collaborate closely with medical providers and primary case management teams at SFHS, Laureate, and other partner agencies to optimize client care and outcomes. The primary work locations will be SFHS patient rooms, with office space at SFHS and/or Laureate. Key functions include implementing strategies to connect high-risk uninsured and underinsured clients with primary care, increasing access to healthcare and community services, assisting individuals in improving their health status, and promoting effective use of the healthcare delivery system.

Requirements

Bachelor’s degree required.
Valid Oklahoma driver’s license required.
Must have ability to work quietly and respectfully in a shared workspace.
Excellent interpersonal and communication skills are required to provide effective health counseling and obtain cooperation from individuals who come from a wide range of economic, social, and ethnic backgrounds.
Demonstrated comfort working in hospital and behavioral health settings and interacting with individuals experiencing physical, behavioral, or mental health challenges.
Skill in operating a personal computer and smart phone applications.
Understanding of healthcare delivery processes.
Skills in obtaining and protecting personal health information (PHI).
Effective interpersonal skills in working with personnel at all organizational levels.
Must maintain THD record confidentiality according to HIPAA regulations.
Must possess ability and willingness to perform job-related travel.

Nice To Haves

Health care, social work, or public health background or education preferred.
One-year experience in health care, social work, or public health preferred.
Previous experience with low-income individuals and engaging culturally diverse individuals in health and social services is preferred.
Bilingual in English/Spanish is preferred, but not required.

Responsibilities

Build trust and rapport with high-risk patients through bedside screening and engagement in hospital, emergency department, and behavioral health inpatient settings.
Provide focused case management by linking enrolled clients to the most appropriate venue for entry into the health care delivery system to include addressing the social determinants of health: transportation, primary care provider, food, utilities, health insurance, medications, housing, domestic violence, and access to internet, phone, and identity.
Coordinate care with SFHS physicians, case management, and other staff to provide coordinated screening for referred patients.
Work with a multidisciplinary health care provider team.
Participate in weekly meetings and visit identified patients in the hospital before discharge.
Coordinate as needed with Tulsa Health Department (THD) services and community partner resources.
Engage clients through home visits and meet clients in community-based settings such as shelters, hospitals, clinics, and partner agency sites, to deliver outreach, support care coordination, and address social determinants of health.
Participate in and attend regularly scheduled supervision meetings; be prepared to share both successes and pitfalls of case management.
Provide culturally and linguistically appropriate services to assigned clients.
Maintain complete and accurate documentation of all activities and reports through computerized data entry in accordance with program standards, guidelines and THD requirements. This includes preparing and submitting paperwork, such as, Workflow List, Enrollment Questionnaires, Client Summaries, and Weekly Caseload List.
Attend regular peer group meetings for networking and information sharing for optimal care management and navigation.
Other duties as assigned including those required to fulfill activities in support of public health emergency operations.
Participate in staff meetings, quality assurance activities, and in-service trainings.
Complete monthly time sheet and mileage forms.