JOB DESCRIPTION:

Case Manager- Primary Care Promotes a strong belief in Adapt Integrated Health Care’s philosophy, purpose, and ideals. In partnership with physicians and /or mid-level providers, the Case Manager will assist in daily patient management services for complex patients and their families by providing in-depth assessments, follow-up care support, small-group educational services, and referral and/or follow up.

QUALIFICATIONS:

• Associate’s degree in Social Work, Psychology, Behavioral Health, or related field; Bachelor’s degree preferred.
• 2 years’ experience in a social service and/or mental health setting
• A satisfactory equivalent combination of education, experience, and training may be considered

• Maintain a presence with BMed providers and PCP teams during clinic hours.
• Facilitate warm handoffs between PCP teams and BMed providers; complete warm handoffs for case management needs
• Provide case management services that support patients in meeting their health goals and that address social determinants of health.
• Identify high risk individuals and determine their level of participation in case management services.
• Encourage maximum self-care activities at home.
• Consult with other health care personnel, and coordinate care of the patient with them.
• Provide necessary follow up as appropriate.
• Initiate enrollment in appropriate social services, social insurance programs.
• Serve as a central resource for community questions/referrals for patients and providers; building relationships with outreach workers, community resources to help identify and solve problems.
• Attend appropriate community/networking meetings to facilitate outreach and gathering of information to increase consumer access to a permanent medical home.
• Anticipate, identify and help patients overcome barriers to care within the health care system, and in their self-care management.
• Support and educate patients in medication management, a home exercise program, nutrition, and health care system navigation as appropriate
• Openly address and acknowledge issues of substance use and also mental illness. Refer to and coordinate with the Behavioral Health Consultant and other appropriate agencies and resources.
• Develop wellness and prevention initiatives.
• Coordinate care with other members of the Health Care Team.
• Notify PCP Team regarding changes in assigned case managed patient’s behaviors, nutrition, exercise, substance abuse, medication adherence, and other issues r/t to the est. care plan.
• Provide accurate and timely documentation of interactions and changes in care plan per Clinic policy.
• Assist the patient and their families in accessing community-based support systems, understanding treatment options and preventive behaviors.
• Coordinate with patients and their insurance companies.
• Be available to assist the Medical Providers as needed in the clinic, especially in case of emergency.
• Be flexible in adding additional job duties that fit with the role of case manager. Examples of these include returning patient phone calls, assisting with UAs, assisting with rooming patients (if qualified), and assisting with administering screening tools.
• Promote a Culture of Safety; reporting hazards, errors and potential patient safety issues
  Monday-Friday 8AM-5P