Essential Job Duties and Responsibilities:

• Effectively manage a caseload and determine appropriate intervention strategies and referral linkages based on the referral type, previous interventions, and information from the provider(s) and client(s).
• Conduct in person, virtual, electronic, or telephone communication with individuals and families to complete assessment, provide education, and connect clients with resources or provide referrals to outside agencies. Complete brief client/family interviews and action plans.
• Provide education to clients on appropriate use of all health care services and promote practice of patient empowerment.
• Utilize principles and techniques of Motivational Interviewing and Stages of Change to appropriately discuss clients’ behavioral changes regarding their healthcare choices.
• Help clients in utilizing resources, including scheduling appointments, and assisting with completion of applications for programs for which they may be eligible.
• Assist clients in accessing health related services, including but not limited to obtaining a medical home, providing instruction on appropriate use of the medical home, overcoming barriers to obtaining needed medical care and social services.
• Inform families of the wide array of early childhood supports and services available in the community and make appropriate referrals.
• Provide de-escalation intervention to clients/providers as needed.
• Provide non-judgmental approach to clients with severe and persistent mental illness and substance use disorders.
• Identify appropriate community agencies or resources for clients, families, and establish referrals and/or empower client/family to seek necessary help.
• Promote positive decision-making, stress management, and coping skills to clients and families.
• Serve effectively as a client/family advocate and supportively allow clients to express ideas concerning provider care and barriers to comprehensive healthcare.
• Document in the database all client and provider consultations, contacts, attempted contacts, and client action plans and interventions; provide timely and professional feedback to providers on outcomes of their referrals.
• Provide technical assistance to and serve as a resource for other team members for questions and information regarding health and social needs and resources. Consistently act as a consultant to other team members, or outside agencies upon referral, request, or self-identification of needs.
• Attend on-going training and education related to case management, empowerment methods, community resources, behavioral health, and health-related topics.
• Conduct client outreach at off-site locations to generate referrals and provide services, as needed.
• Adhere to standards of work for workflow processes and database entry for specific projects as assigned, including for off-site location partnerships.
• Maintain positive relationships with outside community agencies, medical homes, hospital units, and health systems and stay updated on new or existing programs. Act as a liaison between Health Net and off-site partner locations.
• Adhere to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and all related legislation to safeguard Protected Health Information (PHI).
• Represent client and team member perspectives and/or concerns to Management Team.
• Other responsibilities as assigned.

Education. Skills and/or Experience:

• Bachelor of Arts or Bachelor of Science in Psychology, or Bachelor of Social Work degree, or other closely related degree is preferred, with Licensure in State of Michigan where applicable, along with a minimum of 2 years of related experience.
• High School diploma or equivalent required.
• Possess the knowledge, skills and experience necessary to provide effective case management and short-term solution-focused engagement, including basic Motivational Interviewing techniques.
• Valid Michigan driver’s license, automobile insurance and a reliable vehicle.
• Work experience in a health services setting preferred.
• Strong working knowledge of families within the community systems, and/or the Michigan Medicaid system desired.
• Knowledge/experience of the housing and homeless services system and the healthcare system strongly desired.
• Experience conducting office and/or home visits preferred.
• Knowledge/experience with persons with severe and persistent mental illness desired.
• Excellent communication and interpersonal skills needed to provide effective collaboration with clients, family, health care team and any other external entity necessary across the continuum of care.
• Knowledge of local community resources.
• Must be able to work as a part of a team and in a collaborative setting.
• Ability to accept and act upon constructive feedback and verbal or written direction of work.
• Ability to exercise discretion and independent judgment with respect to matters of significance, and perform work related to client complaints, disputes, and grievance resolution.
• Computer skills include a working knowledge of Outlook, Word, Excel, and database systems.

• Demonstrates self-directed, self-motivated, responsible behavior.
• Is able to think independently and make sound judgments.
• Maintains high level of confidentiality and is non-judgmental.
• Is able to use a high level of critical thinking skills in order to make sound assessments, implement plans and re-evaluate health outcomes.
• Demonstrates a high level of cultural competency in the daily performance of duties.
• Informs supervisor of challenges; seeks guidance as needed.
• Is flexible with schedule, tasks and settings.
• Recognizes when there is a need for adjustment and flexibility.
• Supports and cultivates self and fellow team member’s growth and development; remains informed of current changes and trends affecting case management/coordination.
• Assumes responsibility of continuing education and improvement to enhance skills.
• Demonstrates and utilizes knowledge of appropriate resources with the company, health care system, and community.
• Demonstrates excellent customer service performance on all contacts with internal and external customers, with attitude and actions that are consistent with the organizational values listed below.
• Ability to prioritize and manage multiple priorities and projects while meeting deadlines and expectations.
• Ability to discuss and understand the issues that surround health equity and health care systems.
• Follows all federal, state, and local laws/regulations and Health Net of West Michigan policies and procedures

• Employee is regularly required to sit, stand, walk, reach with hands and arms, talk, and hear.
• Ability to lift and/or move up to 30 pounds.
• Moderate level of stress caused by tight deadlines.
• Moderate level of mental and/or visual fatigue and/or eyestrain may result from looking at a computer screen for extended periods of time.
• Occasional travel is required
• Travel within the community to areas which are not barrier free.
• Possible work outside of normal business hours.
• The somewhat open floor plan requires the ability to work in an office environment with moderate noise levels and activity.

• Well-being and Equity - Healthcare is a basic human right. Well-being and equity are foundational elements of our organization in which we work to build a culture that advocates for the well-being of our staff, clients, partners, and neighbors. Our actions, in partnership with community, create space to build trust, mutual respect, honesty, and shared progress towards this vision.

• Collaborate - The framework of our approach relies on mutual trust and co-creation. We elevate the voices of those we serve to influence systemic change by convening stakeholders from a variety of specialties, lived experiences, and backgrounds to develop client-centered approaches to accessing resources.

• Adapt - As an accessible organization, we are both proactive and responsive. We work with clients and partners to implement innovative solutions and streamline system processes to address the needs of our community.

• Respect - We work to dismantle the system of institutional racism and bias that prevents all our clients and neighbors from accessing the tools and resources they need. We honor differing lived experiences and recognize the historical trauma inflicted upon communities of color, LGBTQ, and our neighbors with disabilities. We build trust through consistency and integrity in our relationships.

• Educate - We are students, educators, coaches and collaborators. We equip people with the information they need to navigate the complex healthcare and social services systems by highlighting the natural skills each client has to advocate for themselves and others. We create opportunities to share information and encourage ongoing learning among our staff, partners, and clients.