Case Manager Non-RN EXSteward Healthcare

Position Purpose: Under the direction of Manager, Social Determinants of Health (SDOH), the Care Manager, (SDOH CM) is a trusted member of the Care Management team who facilities the care of high-risk patients faced with social determinant and behavioral health challenges to promote adherence to key components of their health care. The SDOH CM engages patients, creates a trusting relationship, and provides care coordination and management to patients with SDOH challenges who have high rates of emergency department and inpatient utilization and/or significant financial vulnerability. The SDOH - CM provides support and assists members in understanding the implications and complexities of their current situation and/or overall personal care. Key Responsibilities: Provides face-to-face and or telephonic care coordination and care management to patients with social determinant and behavioral health challenges who have high rates of Emergency Department and/or Inpatient utilization and/or severe psychosocial vulnerability Provides care coordination and care management services to patients in the community, and health care settings that patients access Conducts comprehensive care needs assessments with patients, completing a care management treatment plan specific to each member. Assesses, plans, implements, monitors, and evaluates options and services to meet complex psychosocial health needs of patients Addresses barriers to follow through on health care including, but not limited to homelessness/housing instability, financial resources, transportation, childcare, etc. and places referrals to community-based resources as necessary Places external behavioral health and/or substance use community-based resources to assist patient in accessing quality and cost-effective care (i.e. - outpatient therapy, medication management, day treatment, Child Behavioral Health Initiative Services, etc.) Reviews benefits options, research community resources, trains/creates behavioral routines and enables patients to be active participants in their own healthcare Coordinates care with internal and external resources to meet identified needs of the patient's care plan and collaborates with providers Monitors and evaluates effectiveness of care plan and modifies plan as needed Ensures patients are engaging with their PCP to complete their care management treatment plan or preventive care services Acts as a liaison and advocate between the patient, family, physician, and facilities/agencies Interacts continuously with members, family, physician(s), and other resources to determine appropriate behavioral action needed to address medical needs Provides concise and thorough documentation through psycho/social assessment and progress notes, including changes in medical psycho/social functioning, progression and attainment of goals, referrals to internal and external agencies, and contact/involvement with patients family Demonstrates cultural sensitivity and respect for the patient