Work Days: Monday – Friday and Weekends as required
Supervisor: Case Manager Coordinator
Provides services including connecting clients to VA health care benefits or community health care services, care coordination, health education, interdisciplinary collaboration, coordination, and consultation, and administrative duties.
Specific Responsibilities/Essential Functions:
1. Understand the client’s situation, potential barriers to care, the causes, and the impact of such barriers on the ability to access and maintain health care services.
2. Identify the client’s strengths, limitations, risk factors, and internal/external supports and service needs to optimize their ability to access and maintain health care services.
Health Care Team and Communication
3. Assist Clients in communicating their preferences in care and personal health-related goals to facilitate shared decision making of the client’s care.
4. Serve as a resource for education and support for clients and help identify appropriate and credible resources and support.
5. Participate in the development of the care plan by focusing on community services, outreach, and referrals.
6. Regularly review care plan goals with the client and program staff.
7. Conduct regular non-clinical barrier assessments, and provide resources and referrals.
8. Periodically evaluate the effectiveness of the resources and referrals provided and make appropriate modifications.
9. Monitor the client’s progress, maintain comprehensive documentation, and provide information to treatment team members when appropriate.
10. Assist the client in identifying concerns or questions about their treatment or medications.
11. Provide comprehensive case management and care coordination across episodes of care.
12. Act as a health coach by proactively supporting the client to optimize treatment interventions and outcomes.
13. Coordinate services with other organizations and programs to assure such services are complementary and comprehensive.
14. Direct activities to maximize effectiveness, efficiency, and continuity of care.
15. Link clients to supportive services, which include, but are not limited to, housing, financial benefits, transportation.
16. Serve as the subject matter expert on community resources.
17. Collaborate with other providers in the ongoing reassessment of the client’s health care needs.
18. Educate the client regarding the available services and assist in establishing the appropriate referrals based on the client’s preference.
19. Educate the client on the available options for acquiring knowledge and skills for managing health and wellness.
20. Coordinate referrals to VA, community health clinics, and other programs needed to ensure access to health care.
21. Act as an advocate for the client, integrating the client’s cultural values into their care plan.
22. Assist the client in identifying methods to monitor progress toward meeting health goals and provide ongoing follow up.
23. Assist in identifying health education needs and provide education services and materials that match the health literacy level of the client.
24. Provide ongoing education support, as needed.
25. Assist in identifying VA and community resources to prevent disease and promote self-care.
Interdisciplinary Collaboration, Coordination and Consultation
26. Collaborate with other disciplines involved in providing care.
27. Consult with other team members and appropriately assess and address the needs of the client.
28. Understand the different roles within the interdisciplinary team and act within professional boundaries.
29. Adhere to ethical principles about confidentiality, informed consent, compliance with relevant laws, and agency policies (e.g., incident reporting, HIPPA, Duty to Warn).
30. Help identify systemic barriers within the organization; communicate with organizational leadership about these barriers, and work collaboratively to find viable solutions.
31. Serve as the liaison to VA and community health care programs, and represent the program in contacts with other agencies and the public.
32. Build and develop relationships with community leaders, VA staff, and other referral networks to assist connection to services.
33. Schedule meetings with referring agencies to explain program criteria and benefits to increase outreach efforts.
34. Assist in conducting and coordinating outreach activities as assigned.
35. Provide transportation to clients.
36. Attend Trainings that may require overnight and/or out of town travel
37. Perform on call and client services during all shifts, including nights and weekends on an as needed basis.
38. Maintain client confidentiality
1. Bachelor’s degree or Master’s level social worker or equivalent education and experience preferred.
2. Must have an insurable driver’s license
3. Must have reliable transportation available for use during business hours and to perform job duties.
4. Ability to remain calm under pressure and diffuse conflict situations
5. Self-starter with the ability to organize and follow through on assignments
6. Good written and oral communication skills
7. Ability to comprehend and carry out oral and written instructions
8. Must have basic math and computer skills
9. Must be able to communicate with a diverse clientele on a one to one and group setting while maintaining professional boundaries.
10. Must complete a criminal background check with no felony convictions
1. Ability to work in a fast-paced and often high-stress environment, as well as the ability to adapt quickly to workload changes
2. Ability to deal with inside and outside clientele and vendors in a diplomatic and courteous manner while assuring adherence to CAA policies/procedures
3. Above average oral, reading and writing skills to accurately operate a computer, perform necessary documentation and effectively communicate with staff, clients, customers, business partners, other CAA departments, and visitors
4. Frequent sitting, walking, and reaching
5. Occasional lifting (up to 25 lbs.), climbing, pushing, and kneeling
6. Seldom running
1. Numerous interruptions
2. Ability to remain calm and cheerful under stressful working conditions
3. 75% indoors /25% may be outdoors with exposure to odors, dirt, occasional fumes and the general public
Additional Requirements/Conditions of Employment:
1. 90-day probationary period for front line staff and 180-day probationary period for Supervisor, Managers and Directors.
2. Employment is contingent upon the successful completion of a criminal background check.
3. Employment is contingent upon the successful completion of a drug and alcohol test.
4. Employment is contingent upon the successful completion of an employee physical, including a TB test.