SUMMARY: The Targeted Case Manager is a care team member with unique responsibilities that touch all aspects regarding the treatment of the “whole patient,” acting as an advocate to provide information, barrier identification and removal, creating options and problem resolution. The Case Manager embraces a team-based approach and is competent to function as an integral part of the patient healthcare team to improve outcomes for Grace Health patients who are identified as high risk to receive support needed to access healthcare, social needs, education, employment, transportation, housing, legal, or other services. The scope of this role is broad and requires the ability to work independently and with knowledge of community resources available in the area.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Understands and promotes the mission, vision, and values of Grace Health both in the workplace and the community
• Assist patients with the process of re-emergence into daily activities of living while working toward recovery to improve quality of life
• Collect social, educational, economic and vocational information to formulate a plan of care
• Assessment, Treatment, Planning, Linking, Advocacy, and Monitoring of the needs of patients identified as high risk with a diagnosis of substance use disorder or other Mental Health diagnosis
• Create and implement treatment plans involving long and short-term goals
• Connect and refer clients with community resources for healthcare, social needs, education, employment, transportation, housing, legal, community programs, etc. with follow-up assessment
• Understanding and utilization of community resources to optimize assistance and well-being of Grace Health patients for ideal outcomes
• Education of patients, families, and staff about care, prevention, and treatment enhancement techniques
• Facilitate care between Medical and Behavioral Health
• Meets with the patient in intervals, adhering to all company guidelines
• Maintain a positive environment and open communication with patients
• Establish and maintain professional rapport with patients, providers, and other team members
• Build a positive and productive culture in the workplace
• Motivate clients toward goal achievement
• Coordinate care with community providers, hospitals and other facilities to establish a continuum of care
• Participates in facility training and quality meetings
• Maintain accurate and timely documentation
• Evaluate crisis situations and apply appropriate interventions
• Actively participate in meetings that support Grace Health’s integrated healthcare model to provide comprehensive care for clients
• Assist in the detection of “at risk” patients and the development of plans to prevent further psychological or physical deterioration
• Excellent knowledge of social determinants of population served
• Ability to work through brief patient contacts and make quick and accurate clinical assessments of mental and behavioral conditions
• Confidence and comfort with the pace of primary care, strong communication skills and the ability to work with an interdisciplinary team
• Maintain tracking of patient appointments and referrals
• Strong organizational and time management skills
• May require travel to other clinic sites
• 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 improving quality income
• Team members will participate in the review and evaluation processes of practice performance and help identify improvement opportunities
• Team members will participate in Grace Health's advocacy program
  
  

GENERAL DUTIES:

• Provide group, individual, or family case management to clients as assigned
• 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 following all company and HIPAA regulations
• Routinely keep the 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 perform each essential duty satisfactorily. The requirements below represent the required knowledge, skill, and/or ability. Reasonable accommodation may be provided to enable individuals with disabilities to perform essential functions.

SKILLS:

• To perform this job successfully, an individual should have knowledge of Word Processing software
• Excellent working knowledge of behavioral medicine and evidence-based treatments for medical and mental health conditions
• Ability to work through brief patient contacts and make quick and accurate clinical assessments of mental and behavioral conditions
• You should be comfortable with the pace of primary care, working with an interdisciplinary team, and have strong communication skills
  
  

EDUCATION and/or EXPERIENCE:

• The ideal candidate will have at least a bachelor’s degree in arts/science in Behavioral Health or a related field
• Three years or more of experience may substitute for education requirements
• Completion of the 12-hour Targeted Case Management training is preferred and/or will be required after hire
• Previous experience with Case Management Services
• Strong knowledge of Opioid Use Disorder/Alcohol Abuse and Medicated Assisted Treatment and Mental Health
• Continuing Education as applicable
  
  

PHYSICAL DEMANDS: The physical demands described here represent those that must be met by an employee to perform the essential functions of this job successfully. Reasonable accommodation may be provided to enable individuals with disabilities to perform essential functions. While performing the duties of this job, the employee is regularly required to talk or hear. The employee frequently is required to stand, walk, sit, and use hands to finger, handle, or feel objects, tools, or controls. The employee occasionally is required to reach with hands and arms, stoop, kneel, crouch, or crawl, and taste or smell. The employee must occasionally lift and /or move up to 50 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

WORK ENVIRONMENT: Grace Health is a faith-based, federally qualified community health center (FQHC). We provide primary health services to underserved, underinsured, and uninsured individuals in the southeastern Kentucky region. Our mission is “to show the love and share the truth of Jesus Christ to southeastern Kentucky, through access to compassionate, high quality, primary health care for the whole person.” The work environment characteristics described here represent those employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions. The noise level in the work environment is usually moderate.

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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