Assess member needs in the areas of physical health, mental health, SUD, oral health, palliative care, memory care, trauma-informed care, social supports, housing, and referral and linkage to community-based services and supports
Oversees the development of the client care plans and goal settings
Offer services where the member resides, seeks care, or finds most easily accessible, including office-based, telehealth, or field-based services
Connect clients to other social services and supports that are needed
Advocate on behalf of the client with health care professionals (e.g. PCP, etc.)
Utilize evidence-based practices, such as Motivational Interviewing, Harm Reduction, and Trauma-Informed Care principles
Conduct outreach and engagement activities in order to facilitate linkage to the ECM program and log activity in the Client Relationship Management (CRM) system
Evaluate client’s progress and update SMART goals
Provide mental health promotion
Arrange transportation (e.g., ACCESS)
Complete all documentation, including outcome measures within the timeframes established by the individual care plans
Maintain up-to-date patient health records in the Electronic Medical Record (EMR) system and other business systems
Complete monthly reporting to ensure program compliance
Attend training as assigned

2+ years experience as a care manager, care navigator, or community health worker supporting vulnerable populations
Experience working in a remote setting
Working knowledge of government and community resources related to social determinants of health
Excellent oral and written communication skills
Positive interpersonal skills required
Must have general computer skills and a working knowledge of Google Workspace, MS Office and the internet
Bilingual (English/Spanish) preferred

Case Manager

Key skills