Case Manager at Neighborhood Health

PRIMARY FUNCTIONS: As part of an interdisciplinary team within a community health center this position is responsible for providing targeted case management services with behavioral health patients with complex needs and one or more comorbid chronic diseases. The Behavioral Health Case Manager (BHCM) is responsible for providing additional support and addressing unmet needs among the target population, in collaboration with the behavioral health provider, such as researching and facilitating referrals to specialty behavioral health providers in the community when patient needs exceed what Neighborhood Health can provide; providing follow up when a patient is referred for emergency care with a local CSB to ensure linkage is made, and addressing any barriers that may have prevented patient from connecting for higher levels of care. The BHCM may assist patients with completing and/or obtaining necessary paperwork (e.g. screening tools, evaluation reports) from community partners (e.g. school teachers, psychologists etc.); provide follow up safety check-ins with patients experiencing acute exacerbations of symptoms; ensure timely linkage to community partner organizations that can address specific social determinants of health (e.g. housing, SNAP, TANF); and support patients in following through on primary care-related goals such as medication and appointment adherence to address comorbid chronic medical conditions. This individual is responsible for facilitating strong interdisciplinary communication and collaboration within the clinic and among community partners already engaged with the Neighborhood Health patient population.

The BHCM will work collaboratively with public health interns to design interview protocols for a pilot project allowing Neighborhood Health to better understand the needs of patients and the barriers they experience in interactions with the healthcare system and will be responsible for implementing protocols and collecting relevant data for analysis.

The BHCM demonstrates a thorough grasp and sincere dedication to the philosophy and mission of Neighborhood Health.

DUTIES/ RESPONSIBILITIES: (Essential Functions: Duties and responsibilities noted with bullets are considered to be the essential functions of the job)

• Monitors and provides active follow up on referrals to community partners, ensuring timely linkage to care.
• Provides support in the completion of written forms required by systems of care to obtain services (e.g. screening forms, intake forms, applications for services) and ensures receipt of documentation by partner agencies.
• Identifies unmet needs related to social determinants of health not covered by the clinic and provides assistance in obtaining needed resources (e.g. SNAP, TANF, housing, legal aid).
• Provides follow up safety check-ins for patients experiencing suicidal ideation or other acute exacerbation of behavioral health symptoms.
• Provides support for patients referred for emergency care, including facilitating communication with emergency providers, sharing relevant clinical information, and obtaining outcome information from partner agencies on status of referrals and treatment plans.
• Establishes and/or maintains communication with other individuals involved in patient care (e.g. school counselors).
• Responsible for the implementation and enforcement of Neighborhood Health policies and procedures including HIPPA, facility operations, OSHA as pertains to the environment of care.

• Maintains a clean, safe, and compliant work environment according to all federal, state and local laws and regulations including OSHA, HIPAA and Joint Commission.
• Provides administrative support for behavioral therapists including obtaining prior treatment records and ancillary documentation (e.g. IEP).
• Documents all services in the electronic medical record, in accordance with organization’s standards.
• Responds to all communication, both internal and external, in a timely manner.
• Attends and participates in Department and organization meetings by sharing knowledge, experiences, and information regarding team members, clients, work practices, etc.
• May participate in agency workgroups and/or teams.
• Attends and participates in on-going training, learning and growth opportunities.
• Recommends changes in internal policy and procedures based on experience and knowledge.

OTHER DUTIES:

• Prepare and maintain special internal and external reports as requested by Supervisor and/or Department Head.
• Assist with developing, coordinating and recommending changes for the improvement of workflow in the program or section area. 
• May be assigned to various project lead roles to advance the development of the department and support ad hoc needs.
• Able to work under minimal supervision.
• Employee will be asked to perform additional duties and take on other responsibilities as dictated by events and circumstances.

QUALIFICATION/EDUCATION and/or EXPERIENCE REQUIREMENTS:

• Knowledge and experience with behavioral health case management for patients with medical comorbidities.
• Experience with information technology, electronic health records, behavioral health records.
• Bachelor’s degree plus 2 years relevant experience, or Master’s degree, in Social Work, Public Health or Health Administration or relevant field.
• Bilingual fluency in Spanish required.
• 2-3 years direct experience working in a health care or community-based social service setting.

• Experience within primary care environment, preferably with Federally Qualified Health Center.

• Excellent interpersonal communication skills and the ability to work effectively with a diverse work force and patient population.
• Proficient with Microsoft Windows and Microsoft Office, including Word and Excel.
• Must be able to maintain confidentiality with all aspects of information in accordance with practice, State and Federal regulations.
• Must be comfortable working with culturally diverse populations.

• Demonstrate superior critical thinking skills, sound judgment, and decision-making and problem-solving skills.
• Knowledge of local health care environment and basic terminology.