Older Adult Services Case Manager

ZUFALL HEALTH CENTER INC•Dover, NJ

7d•$25 - $29

About The Position

The Case Manager for Older Adults in the ISS Program assists low-income adults age 60 and older in Morris County, along with their families, in accessing appropriate clinical and social services. Services include health screenings, diagnostic testing, primary medical, oral, and behavioral health care, support services, and treatment. The role addresses needs and barriers—including financial, cultural, language, and insurance barriers—that may prevent patients from achieving improved health outcomes. The Case Manager is an integral member of the Care Team and coordinates and manages patient care. Travel throughout Morris County is expected to meet with patients and attend some community meetings. The position is part of the behavioral health department and reports to the Coordinator of Older Adult Services.

Requirements

Excellent knowledge of health and psychosocial issues affecting older adults.
Excellent knowledge of available community services and resources.
Excellent communication and interpersonal skills.
Bilingual Spanish and English proficiency is required.
Ability to interact well with patients, Zufall staff, outside providers, and organizations.
Demonstrated effective follow-through on tasks.
Ability to maintain a high level of confidentiality.
Ability to work independently and complete assignments in a timely manner.
Working knowledge of Zufall policies and procedures and adoption of Zufall’s mission and values.
Ability to work as part of a team.
Ability to learn and apply trauma-informed care principles within the scope of the position.
Calm demeanor and empathetic, patient-centered orientation, including under stressful circumstances.
Knowledge of Microsoft Office and electronic medical records.
Bachelor’s degree in social work or a related field.
At least two years of experience in a clinical or social service setting.

Nice To Haves

Master of Social Work (MSW).
Experience working with older adults.

Responsibilities

Work with the Care Team to identify patients who need services and communicate case progress and unidentified needs to the patient’s healthcare team.
Conduct in-reach with Zufall Health Center staff and outreach to community organizations to encourage referrals.
Conduct intake, determine clinical and social needs, and coordinate an individual plan of care for each patient.
Provide ongoing, intensive case management based on each participant’s identified needs.
Maintain regular contact with participants, including phone or video communication at least monthly, in-community visits every three months, and home visits every six months.
Schedule and coordinate appointments, follow up on missed appointments, arrange rescheduling, contact patients overdue for return visits, and monitor participation in follow-up care.
Help patients overcome barriers to appointments and care, including arranging transportation, interpretation, and translation.
Assist patients with medical and prescription forms and requests to other providers and agencies.
Engage caregivers and family members in the plan of care with the patient’s permission when available or appropriate.
Document interventions and plans in the electronic health record and scan patient-care documents into the record.
Assist medical providers in contacting patients about results, additional procedures, and recommendations for services such as clinical pharmacy.
Educate patients about tests and procedures and explain preparation requirements.
Help patients enroll in appropriate providers, programs, services, or organizations.
Assist patients with applications for Charity Care, Medicaid, NJ Family Care, and other appropriate financial support benefits or insurance.
Support and empower patients in navigating the healthcare system, providing empathy and guidance throughout their healthcare journey.
Advocate for patients with community organizations and governmental agencies.
Establish and maintain external referral relationships with community-based organizations and maintain a referral resource list for older adults.
Track program enrollment, service levels, data, program activities, and expenses.
Attend continuing education trainings related to older adults.
Coordinate with Zufall’s Outreach and Enrollment team to complete at least four outreach or community education activities annually.
Work toward program target objectives.
Perform other duties as assigned.