Benefits:

Competitive salary

Dental insurance

Health insurance

Opportunity for advancement

Paid time off

Training & development

Vision insurance

Mission Statement: To serve God according to His will and purpose by serving our community to the best of our ability with a passion for healthcare and compassion for people.

General Job Description

We are seeking a compassionate, organized, and mission-driven case manager to join our team. The Case Manager plays a vital role in improving patient outcomes through chronic care management, behavioral health integration, and addressing social determinants of health (SDOH). This role combines direct patient support with resource coordination, advocacy, and education to ensure holistic and equitable care.

Qualifications:

Education & Work Experience:

Education: Bachelor’s degree in a health or social work-related field

Work Experience Required: Three to five years’ experience in healthcare or social work field preferred

Skills/Knowledge Required:

· Negotiation skills

· Superior communication skills

· Organizational skills

· Moderate computer/technical skills

· Ability to create, document and follow up with patient’s progression

· Provide health education for individuals and groups

· Develop educational materials like articles, fact sheets and public service announcements for the community

· Set up meetings with providers and patients as needed and informing all necessary parties of the processes involved in each patients’ treatment and the plans for ongoing treatment.

· Keep updated records of each client, collect, and analyze data to evaluate all treatment and recovery programs, and continuously improve patient offerings.

Essential Functions & Responsibilities:

Chronic Care Management

· Manage a caseload of patients with chronic and complex conditions (e.g., diabetes, hypertension, COPD).

· Conduct proactive outreach (phone or in person) to improve adherence, reduce avoidable hospitalizations, and support self-management.

· Collaborate with healthcare providers to create, monitor, and update individualized care plans.

· Document patient interactions, goals, and progress in the EHR using chronic care management tools and billing.

· Serve as the central point of contact for chronic care management.

Case Management & Resource Navigation

· Conduct comprehensive assessments addressing medical, behavioral, and social needs.

· Link patients to community resources including food, housing, transportation, and medication assistance.

· Perform follow-up and ongoing service coordination to ensure barriers are resolved.

· Complete PRAPARE screenings, individualized care plans, and crisis plans within required timeframes and update regularly.

· Provide warm handoffs and immediate support for patients with urgent social needs.

· Conduct Urine Drug Screens

· Take vitals if needed

· Complete GAD-7 at check-in

· Complete PHQ-9 at check-in

· Charting PHQ-9 and GAD-7 in smart forms in encounter notes

· Complete AIMS testing (1:1 testing for side effects of anti-psychotic medications)

· Follow up on telephone encounters (that may not require prescriptions)

· Following up on prior authorizations

Referral Coordination

· Facilitate, initiate, and track referrals for behavioral health, primary care, and community services.

· Collaborate with referral specialists, PCPs, and external partners to ensure patients successfully access services.

· Monitor referral completion, troubleshoot barriers, and follow up as needed.

Patient Advocacy & Education

· Provide education about health, illness, medications, and behavioral health in both individual and group settings.

· Develop and share educational materials (fact sheets, articles, community resources).

· Empower patients with skills to manage their care and advocate for their own needs.

· Actively advocate for patients who face barriers to care, ensuring equitable access to services.

Community Engagement & Collaboration

· Represent the clinic at community events and outreach activities as requested.

· Maintain strong relationships with community partners to strengthen referral networks.

· Collaborate with behavioral health and medical teams for integrated patient care.

· Participate in team meetings, monthly supervision, and interdisciplinary care planning.

Documentation & Compliance

· Accurately and promptly document all patient interactions, assessments, and progress in the EHR.

· Collect and analyze data to evaluate patient outcomes and improve programs

· Ensure compliance with HIPAA and uphold the professional and ethical standards of social work.

· Meet productivity standards as set by clinic policy.