Coordinates screening and providing intervention of patients with identified complex chronic care needs
Acts as a connector between patient needs and resources provided by the care management program
Provides guidance and leadership through the care management program to Esperanza’s care teams
Ensures patients receive the best possible care
Identifies, tracks and manages care for the highest risk patients using electronic medical records
Conducts initial care coordination screening eligibility and performs comprehensive risk assessments
Manages a caseload of 62 patients
Oversees development and implementation of integrated patient care plans
Supports care managers and primary care teams
Ongoing clinical assessment, monitoring and follow up for high-risk patients
Performs medication review and reconciliation
Oversees transitions of care process
Participates in evaluation of care management programs including running data reports
Collaborates in the selection, development and maintenance of patient education materials

Master’s level behavioral health (e.g., MSW) degree
Must have IL licensure (e.g., LSW, LPC)
1-3 years’ experience in disease management or case management
Experience working with medically and behaviorally complex patients preferred
Experience working with children who receive special education preferred
Ability to speak, read and comprehend English and Spanish
Displays strong time management and organizational skills in a high intensity work environment
Knowledge of quality improvement skills preferred
Experience working in healthcare and/or a primary care setting preferred
Flexibility to work evenings and/or weekends, if necessary
Must be able to work on-site as needed
Proficient in Electronic Health Record, Microsoft Word and Excel
Exceptional organizational and interpersonal skills, with attention to detail required; strong oral/written communication skills is a must

Esperanza Health Centers

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