The Clinical Case Manager (CCM) works in collaboration and continuous partnership with patients/caregiver(s), providers, staff and community resources in a team-based approach to assist patients with addressing barriers to healthcare education and services. The CCM functions in the role of clinician, educator, liaison, service coordinator, community resource researcher and resource person to promote quality healthcare.
Duties and Responsibilities:
- Follows up on patients discharged from ER and hospital and makes sure that they have an appropriate follow-up appointment.
- Provides education about the importance of medical care, assists with appointment scheduling, and follow-ups with patients to monitor and address access barriers or other situations that can complicate care or create access barriers (e.g., lack of transportation, uninsured or underinsured, socioeconomic factors, etc.)
- Tracks deliveries and low birth weight babies (<2500 grams) and share results with the Continuous Quality Improvement department monthly.
- Works with patients to gain access to temporary Medicaid while their eligibility for full Medicaid benefits is being determined.
- Serves as a link between patients, providers, community-based agencies and socioeconomic resources in identifying and providing support to patients.
- Follows up on patients who are hospitalized, miss appointments, or require additional support services.
- Performs family and social determinant assessments in collaboration Community Agency/Programs.
- Provides health education and case management to pregnant and newly parenting women, including assessment, referral, follow-up, monitoring and needed supportive services.
- Maintains well-organized, objective, factual, clear, and concise documentation that reflects all case management activities.
- Educates patient and family/caregiver(s) about relevant community resources.
- Collaborates with the Financial Department to ensure all charges related to service line are capture.
- LPN or Associate degree Social Services, Public Health or any other related area; 2-3 years’ experience in clinical or community resource settings; Care coordination and/or Obstetrics case management experience is desirable.
- Demonstrated proficiency in multi-tasking; flexibility; time management; organization, attention to detail; scheduling; professionalism; quality focus.
- Functions well in a team focused environment.
- Local knowledge about and connections to community health care and social resources is desirable.
- Demonstrated computer skills including but not limited to: MS Word, Excel, and Outlook
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