Summary:

Provide ongoing, extended case management as assigned. Coordinate care and referrals to wrap around services that support clinical care. This includes enrollment into insurance and benefit programs for which clients are eligible: transportation, housing, food, behavioral health specialty care and substance abuse treatment. In addition, making proactive contacts to improve patient outcomes and build relationships with health and social services agencies in the community.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Work with crisis intervention, complex and chronic mental illness, and substance abuse in a multi-disciplinary team setting.
• Work with underserved and/or transient populations.
• Work with patients who have co-occurring mental health, substance abuse, and physical health problems.
• Knowledge of general medical practice models and processes such as office procedures, medical records, health insurance, etc.
• Knowledge of clinical data collection and analysis strategies needs assessments and program development.
• Skilled in data collection, tracking, and monitoring.
• Effectively collaborate with other health professionals in a team setting, and work to develop procedures to promote integrated behavioral health access and care.
• Able to multi-task and complete a variety of tasks each day (e.g. phone calls, outreach, referrals, EMR documentation, etc.)
• Other duties as assigned.

OTHER ESSENTIAL DUTIES and RESPONSIBILITIES:

• Grace Health recognizes that managing patient care is a team effort that involves clinical and non-clinical staff. All employees must embrace a team-based approach to patient care and understand that each role is important to our success.
• Team members must demonstrate excellent team communication and coordination to provide quality patient care.
• Care coordination includes communicating with community organizations, health plans, facilities, and specialists.
• Care team members understand and embrace the concept of population management and proactively address the needs of patients and families served by this practice.
• Team members must demonstrate skill and knowledge related to effective communication with vulnerable patient populations.
• Team members must participate in Continuous Quality Improvement activities within the organization to ensure patients receive high quality care.
• All team members will be involved in the process of improving quality outcomes.
• Team members will participate in the review and evaluation processes of practice performance and help to identify opportunities for improvement.
• Team members will participate in Grace Health's advocacy program.

GENERAL DUTIES:

• Follows policies and procedures of the office, including administrative, clinical, quality assurance, and personnel
• Maintain good attendance (daily, meetings, and other assignment tasks)
• Maintain timely documentation of all work assignments
• Maintain patient confidentiality
• Routinely keep supervisor informed about attendance and job assignments
• Flexible in being able to multitask
• Work effectively and at an efficient pace
• Work cooperatively with providers, administration, and peers

QUALIFICATION REQUIREMENTS:

To perform this job successfully, an individual must be able to assist in advancing Grace Health’s mission and to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

SKILLS:

• Ability to be a resource for others and work with providers in the community, as well as knowledge of community resources.
• Ability to effectively engage clients by telephone or in person.
• Knowledge of HIPAA confidentiality requirements as they relate to health care and, specifically, behavioral health.
• Ability to offer understanding and respond effectively and with sensitivity to special populations, such as those defined by race, ethnicity, language, age, sex, sexual orientation, economic standing, disability, migrant and seasonal worker status, homelessness, people living with HIV/AIDS, and others.
• Knowledge of Word Processing software and database programs such as Excel, and the ability to enter information within the Electronic Medical Record.

EDUCATION and/or EXPERIENCE:

Masters in Social Work Preferred, B.S. degree in psychology, social work, counseling or related field, or equivalent education, training, and experience specifically in the behavioral science field considered.

BENEFITS:

• Safe harbor 401(k) with match potential
• Paid time off
• Family friendly work environment
• Health insurance
  • Wellness program
  • Health savings account
  • Pharmacy benefit
  • Employee visits for medical services
• Dental insurance
• Vision insurance
• Life Insurance
• STD/LTD
• EAP & Work life services
• Voluntary benefits
• Hospital indemnity

Grace Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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