In collaboration with patients, families (as defined by the patient) and staff across all disciplines and departments, the case manager will be responsible for providing mental health and substance use interventions, completing psychosocial assessments, referring to appropriate community-based agencies, and addressing the social determinants of health for patients. As part of CommUnity Care’s Street Medicine team, the case manager will provide supportive services and outreach to patients experiencing unsheltered homelessness at a variety of community-based settings including encampments and local homeless service agencies. This person will determine resources needed to obtain maximum possible benefit from all available resources.

Essential Duties (at least 5 that are non-negotiable duties and are absolutely pertinent to successfully completing the job without accommodations):

• Assess current needs of patients by conducting interviews with patients and/or family members
• Develop and implement individual treatment plans.
• Initiate appropriate referrals for patients to mental health and/or substance use treatment as needed and/or to appropriate community‐based resources.
• Provide and research current and most effective community resources.
• Address personal and environmental issues with the patient in order to maximize emotional, social, and physical wellbeing and the appropriate use of healthcare resources.
• Advocate for clients in the community (i.e. court, housing facilities, rehab, etc.).
• Determine healthcare coverage and aid in enrolling in appropriate healthcare coverage.
• Track client progress.
• Provide outreach as needed.
• Assist medical staff with patient care (i.e. medication, patient transportation, medical beds).
• Provide brief crisis interventions as needed.

• Attend patient care (unit) huddles and periodic informational (clinic) huddles, meetings, patient conferences, or planning sessions. These may be related to quality assurance, patient care and other related topics within the clinic.

• Ensure all tasks provided and associated with patient care, patient administrative processes and related duties comply with all regulatory and accreditation standards including The Joint Commission and CommUnityCare Standard Operating Procedures and CommUnityCare Policies and Procedures.

• Develop and maintain favorable internal relationships, partnerships with co-workers, including clinical managers, clinical support staff, providers and business office staff.

• Participate/serve on planning committees for events developed and hosted by CommUnityCare and/or other service organizations.
• Perform other duties as assigned. 

Knowledge/Skills/Abilities:

• High level of skill at building relationships and providing excellent customer service.

• High level of problem-solving skills and flexibility to better serve patients and staff.

• Strong attention to detail and accuracy.

• Excellent verbal and written communication skills.

• Demonstrated knowledge of community resources available and how to access resources for the benefit of clients.

• Demonstrated success in collaborating with multidisciplinary team members.

• Bilingual (Spanish/English) preferred.

• Utilize electronic medical record to compile data/information for reports.

MINIMUM EDUCATION:  

• Bachelor’s degree in social work or similar field

MINIMUM EXPERIENCE:

• Internship or work in a field related to social work, case management or counseling individuals in crisis/trauma situations.
• Demonstrated knowledge of community resources available and how to access resources for the benefit of clients.

REQUIRED CERTIFICATIONS/LICENSURE:

• Valid driver’s license.

REQUIRED COURSES/COMPLETIONS (e.g., CPR):

• Basic Life Support (BLS) ‐ Obtained through approved American Heart Association Training Network