Older Adult Services Case Manager

Zufall Health Center•Dover, NJ

About The Position

The Case Manager for the Older Adults ISS Program assists low-income adults aged 60 and older who reside in Morris County, along with their families, in accessing appropriate clinical and social services. These 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 for patient visits and 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 the health and psychosocial issues of the older adult population.
Excellent knowledge of available community services and resources.
Excellent communication and interpersonal skills.
Bilingual Spanish/English required.
Ability to interact well with patients, Zufall staff, outside providers, and organizations.
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.
Ability to maintain a calm demeanor and empathetic, patient-centered orientation under stressful circumstances.
Knowledge of Microsoft Office and electronic medical records.
Bachelor’s degree in social work or a related field.
Minimum of two years’ experience in a clinical or social service setting.

Nice To Haves

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

Responsibilities

Work as part of the Care Team to identify patients needing services and communicate case progress and unidentified needs to the patient’s healthcare team.
Conduct in-reach to Zufall Health Center staff and outreach to community organizations to encourage referrals.
Conduct patient intakes, determine clinical and social needs, and coordinate an individual plan of care.
Provide ongoing, intensive case management based on participants’ identified needs.
Maintain regular participant contact, 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, reschedule as needed, contact patients overdue for return visits, and monitor participation in follow-up care.
Help patients address barriers to appointments and care, including arranging transportation and interpretation or translation services.
Assist patients with medical and prescription forms and requests to other providers and agencies.
Engage caregivers or family members in the plan of care, with patient permission whenever available or appropriate.
Document interventions and plans in the electronic health record and scan relevant patient-care documents into the record.
Assist medical providers in contacting patients about results, additional procedures, and recommendations for services such as clinical pharmacy services.
Educate patients about tests and procedures and provide instructions for preparation.
Facilitate patient enrollment in appropriate providers, programs, services, and organizations.
Assist patients with applications for Charity Care, Medicaid, NJ FamilyCare, and other appropriate financial support benefits or insurance.
Support and empower patients to navigate 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 develop and maintain a referral resource list for older adults.
Assist with tracking program enrollment, service levels, program activities, data, 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 and perform other duties as assigned.