Job title: Complex Care Manager
Department: Community Health Department
Reports To: Chief Clinical Officer
Salary Level: Grade 20
FLSA Status: Exempt
Approved By: Chief Executive Officer
Approved Date: May 9, 2025
GOALS FOR POSITION: The goal of the program will be to assist patients to achieve optimal health and/or independence in managing their care. To achieve this goal the CCM will demonstrate and apply knowledge of the philosophy/principles of comprehensive case management, patient-centered, culturally sensitive care coordination and management of complex patients.
SUMMARY: The Complex Case Manager will be responsible to develop plans for patient and family self-care competence, including motivational assessment, assessing for desired level of involvement and coaching for adherence to the care plan. CCM will provide assessments, create and monitor patient/ family care plans including end of life planning. The primary contact with the patient, family and other loved involved care providers will be by telephone, and electronic medical record. Case manager promotes knowledge of this program throughout the Hoopa Valley, and wherever Kimaw Medical Center medically homed patients live and receive care. In addition she s/he is responsible to create sustained partnerships with community resources and support agencies
FUCTIONS & RESPONSIBILITIES
- Provide appropriate interventions which demonstrate knowledge of and sensitivity toward cultural diversity and religious, developmental, health literacy, and educational backgrounds of the population served. Utilize interpreter services per policy.
- Perform a psychological/social assessment including barriers to coping, mental health history, cognitive development, adverse developmental events, resistance to treatment, mental health symptoms, and learning, and /or mental health threat, residential stability, health system impediments, social support, and vulnerability.
- Assess eligibility of uninsured and underinsured patients for federal, state, and community programs to assist funding of medical care. Assist patients with processing paperwork and collaborate as needed.
- Assess for depression including PHQ2, PHQ9, and suicidal/homicidal patients and determine crisis response/action to take for resolution.
- Educate patients on advanced directives and Advanced Care Planning and assist with the completion of documents. Address end of life issues in collaboration with others.
- Centralize coordination and oversight of social service programs.
- Guide the patient in prioritizing concerns and formulating questions to prepare for interactions with providers.
- Function as a liaison to community programs, participate in community groups, and maintain a network of appropriate contacts to identify potential resources for meeting patient needs.
- Demonstrate theoretical knowledge of family systems and clinical practice in negotiating with patients and families “in crisis” to gain conflict resolution.
- Guide employees regarding difficult patient situations. Help to defuse difficult/aggressive patients when possible, including making decisions for 911 interventions.
- Accurately identify and prioritize high needs/risk cases. Help obtain and/or provide health education.
- Promote empowerment of patient in self-management of disease. • Establish collaborative relationships with clinic and site managers and other professionals within and outside of Kimaw Medical Center.
- Conduct visits to clinics to enhance awareness of Patient Resources’ services. Provide internal training and community outreach as needed.
- Immediately advise managers, physicians, and/or staff in the event of a critical incident and contact patient as needed.
- Provide consultation to health care team on areas of expertise
- Create and distribute reports as requested (example: Social Service Clinic Reports, quarterly Urgent Care report).
- Identify, address, and report quality issues identified through work or data sources.
- Participate in meetings and organizational groups as requested
- Accurately assess patient social service needs such as family functions and coping, financial barriers, legal issues, emotional, behavioral, and mental health needs, support systems, etc. and reflect multidisciplinary collaboration in assessment
- Utilize expert knowledge of community or agency resources to assist the patient and family to achieve highest possible level of functioning. Make referrals to appropriate areas and assist with arranging services per the needs of the patient/family
- Collaborate with clinical staff and patient/family to develop and execute patient/family centered care plans and goals, integrating referrals to appropriate community resources into care plan. Assist patient, family, social relationships, medical staff, and teammates with care coordination, problem solving, and goal setting.
- Reassess and modify care plans/goals with patient/family at agreed upon intervals to achieve desired outcomes in the desired timeframe
- Assure implementation of care plans throughout the continuum of care to include a variety of settings (i.e., hospital, assisted living, etc).
- Utilize motivational interviewing techniques to support goals and reduce barriers to achieving them
- Utilize motivational interviewing techniques to support goals and reduce barriers to achieving them. • Provide individual and family support and engage them in treatment plan and decision-making process with respect to patient rights, principles of confidentiality, respect for patient privacy, and right to self-determination.
- Participate in replication of program services to other populations as requested.
- Conduct in-home, in clinic, or inpatient hospital comprehensive assessment as needed.
- Other duties as assigned
Skill in:
- Planning, assigning, directing, and reviewing the work of others.
- Managing a complex caseload and establishing priorities for case management, treatment, and referrals.
- Applying the principles of epidemiology to a wide range of social and health problems.
- Identifying community health needs through analysis of demographic and biostatistical data and information.
- Exercising sound independent judgment within established guidelines.
- Assessing normal and abnormal health and behavior, finding, and developing effective treatment and referral plans.
- Communicating clear and accurate information regarding clients to physicians, health providers and other health members.
- Following up on recommended treatment plans to ensure effective resolution of health and related problems.
- Preparing clear, complete, and accurate documentation, reports, and other written materials.
- Providing group and individual health care instruction.
- Assisting in the evaluation of Community Health Outreach Program effectiveness.
- Establishing and maintaining effective working relationships with clients, public and private social and health agencies, physicians, and the public.
- Proficient in treatment and procedures carried out in the ambulatory care setting and home setting, wound care, urinary catheter, dressing changes etc.
MINIMUM QUALIFICATIONS:
{Preferred) Education: Licensed Clinical Social Worker (LCSW), Master’s Degree in Social Work (MSW) or Registered Nurse (BSN preferred) with current unrestricted license in the state of California (BSN preferred).
EDUCATION and/or EXPERIENCE:
Licensed Clinical Social, Worker (LCSW), Master’s Degree in Social Work (MSW) or Registered Nurse (BSN preferred) with current unrestricted license in the state of California (BSN preferred).
At least 5 years’ clinical experience in acute care setting is preferred.
At least 2 years insurance related experience preferred.
CERTIFICATES, LICENSES, REGISTRATIONS:
- Current CPR, ACLS, and PALS certificate (or obtain ACLS and PALS within 2 months of employment)
- Valid California Drivers License
- Valid RN licensure, BSN and/or PHN Certification preferred.