Job description

Position Summary:
Under the supervision of the Utilization Management Manager, the Case Manager is responsible for constructing a comprehensive care plan and providing a range of care coordination services; including but not limited to, monthly health interviews with patients, coordination with family members and caregivers, and working with community services to ensure access to care. The Case Manager is comfortable in providing guidance and completion of needs assessments, development of patient-focused care plans, periodic reassessments, and comprehensive service coordination (such as assisting with access challenges, developing relationships with service providers, and tracking interventions and outcomes). In addition, the Case Manager will provide telephonic Care Management (non-face-to-face) services, as an extension of the clinical staff of SYHealth, managing patients with 2 or more diagnosed chronic conditions.

Essential Functions of the Job:

• Develop an individualized comprehensive plan of care integrating primary care and community support services to achieve the whole-person health goals designed with interventions to improve functional status, health status, or prevent decline.
• Identify and initiate referrals for social service programs; including financial, psychosocial, community and state supportive services integrating community social supports into the comprehensive care plan to include mitigating housing instability and homelessness.
• Provide a complete continuum of quality care through close communication with members via in-person or telephone interaction assisting clients in navigating health, behavioral health, and social services systems, and transitions of care; identify barriers to goals and support clients and caregivers through advocacy to ensure client needs and choices are fully represented and supported by their health care team.
• Review individual care plans and make monthly phone calls and/or in-person visits to CCM and ECM enrolled patients. These may include:
• Assess current health status.
• Medication reconciliation & compliance assessment, as appropriate.
• Appointment reminders.
• Appropriate patient education regarding the patient’s condition management at home/community.
• Review orders, labs, consults, and associated documentation; as indicated by clinical providers.
• Encourage and provide resources on preventative health services.
• Thorough documentation in the patient’s electronic health record regarding the care plan reflecting outreach, communication, updated information, test results, social determinants, and any additional required documentation according to the patient’s care plan.
• Manage the flow of information to/from provider’s office and/or community resources to the patient and appropriate caregivers.

Manage caseloads according mandated program requirements to ensure compliance with timely completion of care planning, follow up activities, documentation and submission timeframes, and all components of patient engagement.
Prepares and submits productivity reports daily, weekly, and/or monthly by pre-determined deadlines; as required.
Maintains a comprehensive care management structure: complete electronic care plan, perform care coordination, assist with transitions of care along with other care management services, record patient health information, and communicates timely key patient health information, and provides health promotion and additional services to help members with community and social services (such as housing, transportation, and food), as required.
Utilizes the Primary Care Medical Home model to provide coordinated Team Care that addresses current diseases and facilitates inter-disciplinary management for preventative and health maintenance follow-up for patients enrolled in ECM.
As required, meets with the clinic Care Team and other community resources to identify and implement actions for improving population management outcomes.
Reinforces information given to the patient and/or family with handouts to improve patient self-management skills and communication.
Acts as a point of contact for patients and families for asking questions and raising concerns.
Serve as an advocate for patients by creating a bridge between them and community agencies.
Positively impacts patient experience by demonstrating values of Transforming Care including, but not limited to courteous and helpful behavior and a commitment to accuracy.
Facilitates referral from SYHealth and community resources for assistance with other needs and complex issues.

Additional Duties and Responsibilities:

• Maintains established departmental policies and procedures, objectives, quality assurance programs, safety, environmental and infection control standards.
• Works effectively with people from diverse cultures and socioeconomic backgrounds.
• Enhances professional growth and development through participation in educational programs, current literature, in-service meetings and workshops.
• Attends meeting as required and participates on committees as directed.
• Participates in outreach events, as required.
• Performs other related duties as assigned or requested.

Job Requirements: Education Required (Minimum level of education):
Bachelor's degree (Social Work, Psychology, or a related Health/Human Services field) or Licensed Vocational Nurse certification.
A minimum of 3 years’ experience in chronic care and/or disease management with minimum of 1 year of experience in a healthcare setting, providing direct patient care may be considered in lieu of a bachelor’s degree or LVN.

Certifications/Licenses Required:
CA driver’s license and vehicle with appropriate insurance coverage. Local travel is required for work in the field for this position.

Experience Required (Minimum level of experience):
2 years of experience in chronic care and/or disease management with minimum of one year of experience in a healthcare setting, preferably providing direct patient care, or with duties encompassing patient education, advocacy, and navigation of connections across complex health systems and community services. Resourceful community liaison required with experience in managed care and clinical quality helpful.

Verbal and Written Skills Required to perform the Job:
Good written and verbal communication. Bilingual strongly preferred.

Working Traits:
Superb organizational ability and exceptionally analytical. Willing and able to work in different environments, including being office based and spending time on the ground within communities.

Technical Knowledge and Skills Required to Perform the Job:
Experience and proficiency with Microsoft Office software; especially Excel. Experience managing EHR system.

Equipment Used:
Personal Computer and/or Laptop

Working Conditions and Physical Requirements:
Prolonged periods of sitting, and constant walking and standing. Driving and travel required. The employee may be in contact with individuals and families in crisis who may not be attentive to basic personal hygiene, health, and safety practices. The employee must be ready to respond quickly and effectively to many types of situations.

About Us San Ysidro Health is a Federally Qualified Health Care organization committed to providing high quality, compassionate, accessible and affordable healthcare services for the entire family. The organization was founded by seven women in search of medical services for their families and community. Almost 50 years later, San Ysidro Health now provides innovative care to over 108,000 patients through a vast and integrated network of 47 program sites across the county. San Ysidro Health could not serve our patients without the dedication of our passionate and hardworking employees. Apply today and become a part of our mission-driven team! San Ysidro Health has a long-standing commitment to equal employment opportunity for all applicants for employment. Employment decisions including, but not limited to, those such as employee selection, performance evaluation, administration of benefits, working conditions, employee programs, transfers, position changes, training, disciplinary action, compensation, and separations are made without regard to race, color, religion (including religious dress and grooming), creed, national origin, nationality, citizenship status, domestic partnership status, ancestry, gender, affectional or sexual orientation, gender identity or expression, marital status, civil union status, family status, age, mental or physical disability (including AIDS or HIV-related status), atypical heredity cellular or blood trait of an individual, genetic information or refusal to submit to a genetic test or make available the results of a genetic test, military status, veteran status, or any other characteristic protected by applicable federal, state, or local laws.

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