Geriatric Case Manager

Finger Lakes Community Health (FLCH) was founded in 1989 with an original mission of serving the region's agricultural workers by linking individuals to area resources and providing essential health services. In 2009 the organization expanded to become a Federally Qualified Health Center (FQHC), serving patients of all incomes, ethnicities, and walks of life. Over the last decade, FLCH has grown to provide medical, dental, and behavioral health services to over 28,000 patients at eight health centers.

With over 200 employees we strive to provide high-quality and innovative health care services to the Finger Lakes Region.

• Monday through Friday schedule, closed all major holidays
• Medical, Dental, Vision, and Life insurance
• Safe Harbor 3% 401k contribution
• Robust PTO offerings
• Education reimbursement

The Geriatric Case Manager provides client-centered care planning and support for Finger Lakes Community Health patients aged 60 and older. This position assists patients in navigating healthcare and social service systems, reducing barriers to care, and promoting improved health, safety, and independence.

This position will work out of the Geneva Community Health Center, but will travel to the surrounding counties.

• Identify eligible patients through referrals, EHR review for high utilization, and participation in morning huddle
  meetings.
• Assess socio-economic factors impacting health and develop individualized health and social management goals.
• Assist patients in accessing healthcare and social services and overcoming barriers to care.
• Complete an annual fall-risk assessment and annual Health Related Social Risk Screen with each patient at
  minimum.
• Guide patients in prioritizing needs and establishing achievable goals.
• Establish a communication strategy with patients, promoting the use of electronic-assisted devices to
  communicate with peers, providers, and community agencies.
• Coordinate or arrange transportation for patient appointments at Finger Lakes Community Health or external agencies, based on insurance eligibility, which may include direct patient transport when appropriate.

• Communicate the patient’s plan of care with providers, care managers, and external partners to ensure shared
  understanding of patient goals.
• Review care documentation to identify gaps or inconsistencies in treatment and collaborate with providers to
  address in alignment with the care plan.
• Maintain ongoing communication with the care team to align on updates, concerns, and progress toward
  patient goals.
• Participate in patient appointments or team meetings to remain informed on care progress and changes.
• Refer patients to appropriate community resources and outside agencies, including Social Services, to support
  care needs.

• Reassess the patient care plan annually or upon significant life changes.
• Record case details, demographics, services provided, and referrals in the electronic health record system.
• Address telephone encounters, actions, and referrals in the electronic health record system in accordance with
  Finger Lakes Community Health policies and procedures.

• Perform other related duties as assigned by the supervisor.

• Sitting/Standing:
  Prolonged sitting with occasional standing or walking.
• Computer Use:
  Frequent typing and prolonged screen time.
• Light Lifting:
  Frequently lifting or carrying objects up to 15 pounds.
• Visual:
  Clear vision for reading and inspections.
• Hearing Clarity:
  Ability to hear conversations in person or in virtual communications

• Health Center/Clinic:
  Work within a healthcare facility, interacting with patients and staff.
• Outreach:
  Outreach work within community and field…