Case Manager, CHP

Case Manager Supported with funding from Ascension St. John (ASJ), this partnership represents an exciting opportunity for Tulsa. The goal of the partnership is to improve health disparities in the Tulsa community, decrease re-admission rates and inappropriate emergency room usage, and increase the use of primary care providers to improve patient health outcomes. The Case Manager (CM) will help the Community Health Program (CHP) attain its program success and improve the health of patients. Provide case management services for Community Health Program clients. Coordinate referrals to community agencies for additional assistance, treatment, and continuity of care. Complete electronic documentation of each patient contact. CMs will work closely with medical providers and primary case management teams at ASJ and other agencies to improve patient care and outcomes. CMs will primarily work out of ASJ patient rooms and client homes with office space at Central Regional Health Center. CMs will implement effective strategies for linking high risk uninsured and underinsured clients to primary care/medical homes; increase access to appropriate health care and community-based services; assist individuals in improving health status; and promote behavior change in using the health care delivery system. The following functions represent the majority of the duties performed by the position but are not meant to be all-inclusive or prevent other duties from being assigned when necessary. Create a trusting, comfortable, and respectful environment that fosters partnership and engagement with "High Risk" clients from all backgrounds. Provide focused case management by linking clients to the most appropriate venue for entry into the health care delivery system to include addressing the social determinants of health: transportation, primary care provider, food, utilities, health insurance, medications, housing, domestic violence, and access to internet, phone, and identity. Coordinate care with ASJ physicians, case management, and other staff to provide coordinated care for patients. Work with a multidisciplinary health care provider team. Participate in weekly meetings and visit identified patients in the hospital before discharge. Coordinate as needed with Tulsa Health Department services and community partner resources. Participate in and attend regularly scheduled supervision meetings; be prepared to share both successes and pitfalls of case management. Provide culturally and linguistically appropriate services to assigned clients. Maintain complete and accurate documentation of all activities and reports through computerized data entry in accordance with program standards, guidelines and THD requirements. This includes preparing and submitting paperwork, such as, Workflow List, Enrollment Questionnaires, Patient Summaries, and Weekly Patient List. Attend regular peer group meetings for networking and information sharing for optimal care management and navigation. Other duties as assigned including those required to fulfill activities in support of public health emergency operations. Participate in staff meetings, quality assurance activities, and in-service training. Complete monthly time sheet and mileage forms. Bachelor's degree required with a preference for a degree in health care, social work, or public health. One-year experience in health care, social work, or public health preferred. Previous experience with low-income families and engaging with culturally diverse families in health and social services is preferred. Excellent interpersonal and good communication skills are required to provide effective client counseling and obtain cooperation from clients who come from a wide range of economic, social, and ethnic backgrounds. Skill in operating a personal computer and smart phone applications. Understanding of healthcare delivery processes. Skills in obtaining and protecting personal health information (PHI). Effective interpersonal skills in working with personnel at all organizational levels. Must have ability to work quietly and respectfully in a shared workspace. Regular internal contact with various nurses and case managers to coordinate care or referrals for patients. External contact with community partners for the coordination of care and referrals for clients. Must be able to walk between the CM floor to patient rooms. Must be able to drive to home visits. Must be psychologically able to tolerate difficult patients. Direct Supervision – None Indirect Supervision – None Budget/Money/Material – None Reports to – Supervisor of the Community Health Program Location – Central Regional Health Center High pace, high volume hospital. Regular exposure to clinic environments as well as travel to and visits within patient homes where various living conditions may be encountered. Must maintain THD record confidentiality according to HIPAA regulations. Must possess ability and willingness to perform job-related travel. Non-exempt