RYAN WHITE - MEDICAL CASE MANAGER TIER I, II, or III

ANCHORAGE NEIGHBORHOOD HEALTH CENTER INC•Anchorage, AK

3d•Onsite

About The Position

The Medical Case Manager (MCM) serves as a patient advocate, supporting, guiding, and coordinating care for patients, families, and caregivers within a primary care clinic. The MCM manages a caseload of patients, coordinating resources across the care continuum and working to optimize both health outcomes and resource utilization. The case manager facilitates communication among patients, providers, and community-based organizations, ensuring patients receive timely and appropriate care services. The MCM is embedded within and integral part of the primary care team.

Requirements

Experience working with vulnerable or underserved populations.
Three years' experience in patient/client-facing roles in healthcare or social series.
Undergraduate degree in social work, psychology or related field; experience may be substituted on a year-by-year basis.

Nice To Haves

Experience in a primary care or safety-net clinic setting preferred.
Bilingual preferred.

Responsibilities

Manage a panel of patients to coordinate care and services across ANHC, external specialty providers, and local community resources.
Act as a central point of contact, coordinating and integrating services across the service continuum.
Conduct comprehensive assessments to identify patient’s level of service need and to determine appropriate interventions and support.
In conjunction with the patient and the primary care team, develop individualized care plans with short and long-term goals to support patients with health goals.
Update care plans at appropriate intervals.
Monitor patients’ progress, evaluate outcomes, and adjust care plans as needed.
Assist patients in identifying and accessing needed resources to meet care plan goals.
Provide ongoing follow-up, support transitions of care (e.g., referrals, follow-up appointments, discharge or changes in care levels), and ensure continuity of care.
Act as a patient advocate; elevate patient voice so that preferences are respected and needs are met within the healthcare system.
Empower patients by highlighting personal agency.
Educate patients on rights and responsibilities within a healthcare setting.
Provide education to patients and their support systems about diagnoses, treatment plans, self-management strategies, and how to access community or social support services.
Provide emotional and social support to help patients and their families navigate the emotional toll associated with diagnosis and/or treatment.
Provide information on screenings, preventative care, and chronic care management.
Explain medical information in an easy-to-understand manner, tailoring education to the patient’s health-literacy level.
Work closely with the primary care team including medical providers, nurses, behavioral health, community resources, and other team members to ensure coordinated, holistic care.
Maintain open communication with primary care provider and other members of the care team to ensure.
Maintain accurate, timely, and confidential records of assessments, care plans, interventions, progress notes, and communications.
Ensure compliance with legal, ethical, and regulatory standards regarding privacy and data security.
All other duties as assigned.
Participates in quality improvement activities.
Elevates care trends needing improvement and works collaboratively within a team setting to identify and implement solutions.
Attends and participates in meetings and activities as required.
Serves as a member of site committees, as requested.
Complete all required trainings as deemed necessary for this position