Job Description

Schedule: Monday - Friday
Salary: $28.30 - $42.44 Depending on Qualifications

JOB PURPOSE: The Care Coordination Case Manager provides provision of a whole person, integrated, accessible, and equitable health care by interprofessional teams who are accountable for addressing the majority of an individual’s health and wellness needs across settings, and through sustained relationships with patients, families, and communities.
The Care Coordination Case Manager works with patients and a multidisciplinary team in identifying social drivers of health that are a barrier toward health equity. Assesses and utilizes credible tools to evaluate social drivers of health and develop individualized care plans for the patient and family. Prepares needs assessments and engages the multidisciplinary team to collaborate services and community resources. Improves understanding of access points for medical care, resulting in decrease emergency room visits and hospital admissions and re-admissions.

Essential Job Functions:
• Serves as ongoing primary contact for Care Coordination Registered Nurses who need assistance with care for their managed patients.
• Provides non-judgmental care to patients, taking into account assessment and motivational interviewing techniques, identifying psychosocial, physical, education, and linguistic needs.
• Develops a comprehensive individualized plan of care and targeted interventions that involve patient/family in the decision-making process. Includes patient’s goals, preferences, and care team’s treatment goals.
• Continually monitor’s patient/family response to plan of care and revise as needed. Interprets nature of illness and prescribed course of treatment to patients and families; communicates family issues to other staff members; participates in planning conferences.
• Maintains records, patient registries, and documented follow up to ensure patients receive continuity of care whenever possible.
• Acts as a liaison between providers, provider teams, patients, families, and community, arranging transitions of care plans.
• Coordinates cases between the health care team and payors.
• Partnering with the Leadership team on initiatives focused on reducing emergency room visits and hospital admissions and re-admissions.
• Collaborates in ongoing innovation of the Care Coordination team.
• Provides services to all El Rio Health Centers staffed by a Registered Nurse Care Coordinator, in-person and via telephone. Potential travels to various health centers throughout the work week to provide care.
• Coordinates access to community resources for patients needing socio-economic support, including food and shelter.
• Maintains an updated list of community resources.
• Using data systems to monitor gaps in care.
• Consistently demonstrates AIDET principles and serves as a role model for service excellence with all patients/visitors, colleagues, and the community.
• Maintains a clean, safe, and hygienic work environment in compliance with all Policies and Procedures including but not limited to work areas, workstations, examination rooms, hand washing, infection prevention and control etc. for this position.
• Demonstrates an understanding of and proficiency with the application of all compliance and reporting requirements respective to Joint Commission Certification (JCC) standards.

Minimum Education and Experience:
• Master’s Degree in Social Work, Psychology, Sociology, Public Health or related field from an accredited college or university.
• Three (3) years’ experience working with patients in a healthcare or related environment.
• Experience doing care coordination.

If applicable, equivalent combination of education and experience may be considered, and must be directly related to the functions and responsibilities of the job.

Required Licenses, Certifications, and Registrations:
• Current certification in Basic Life Support (BLS) for health care providers.
• Level I fingerprint clearance card: current valid and in good standing or have applied for it within seven working days after beginning employment.
• Employees in this position are required to have reliable transportation that can meet any operational reassignments of the organization during the workday. If an employee is driving during work hours, the employee is required to possess a valid driver’s license and must comply with Arizona vehicle insurance requirements.

Preferred Education, Experience, Skills, Abilities:
• Five (5) years’ working experience in community health centers or primary care.
• Previous training in Crisis Intervention, Non-Violent Crisis Intervention, and/or related intervention care models.
• Bilingual (English/Spanish) with the ability to speak, read and write in both languages.

Reasonable accommodations may be made to enable individuals with disabilities; known limitations related to pregnancy, childbirth, or related medical conditions; and for sincerely held religious beliefs, observances, and practices to perform the essential functions of the job.
El Rio Health does not discriminate based on race, color, religion, sex (including pregnancy, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, or other non-merit-based factors. It is our intention that all qualified applicants be given equal opportunity and that selection decisions are based on job-related factors.
El Rio Health requires all AZ employees to have a Level One Fingerprint Clearance card. A.R.S. 36.425.03. New hires and transfers must submit their fingerprint clearance card or fingerprint receipt before their hire date or transfer date. Level One (1) Non-IVP Fingerprint Clearance card must be received within 30 days after the new employee hire date or transfer date.
All employees are strongly recommended to obtain and maintain vaccination status (i.e., as recommended by CDC and/or other public health agencies) to include an Influenza vaccination. Subject to exemptions and accommodations when required by law. (Policy: Adm-016 & Adm-045).
All employees are required to undergo drug testing prior to employment and will be subject to post-accident, reasonable suspicion, return to duty and follow up drug and alcohol testing in compliance with Federal and State regulations for alcohol and controlled substance testing. Employees in positions holding responsibility for the safety and welfare of others will also be classified as safety sensitive.
El Rio Health is a non-profit 501(c)(3) Federally Qualified Health Center (FQHC) and abides by all applicable federal Drug-Free Workplace standards. El Rio Health is an equal opportunity employer.