Case Manager

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Behavioral Health Full Time Norfolk, NE, US

Job Summary:

The Case Manager provides patient-centered case management, care coordination, and community health support to help patients overcome barriers to care and access needed medical, behavioral health, social, and community services. The Case Manager works collaboratively with patients, families, providers, the Nurse Case Manager, specialists, and community partners to promote continuity of care and support positive health outcomes.

The Case Manager assists patients with social determinants of health, referral coordination, transitions of care, missed appointments, chronic disease self-management, and connection to community resources. The position serves as a liaison between patients and members of the multidisciplinary care team and provides education, navigation, motivational support, and follow-up to help patients achieve individualized health and wellness goals.

Supervisory Responsibilities:

None

Duties/Responsibilities:

• Provides patient-centered case management and care coordination to assigned patients, helping identify barriers to care, establish patient-driven goals, and connect patients with appropriate medical, behavioral health, social, and community resources.
• Assesses and addresses social determinants of health (SDOH) by screening patients, helping to identify, prioritize, and address barriers such as transportation, housing, food insecurity, financial concerns, utilities, safety, and access to care.
• Coordinates referrals and community resources by assisting patients with scheduling, completing applications, obtaining needed information, and tracking referrals through completion or resolution. When appropriate, may assist patients with or accompany them to appointments.
• Tracks emergency department visits and hospitalizations and assists with follow-up and transitions of care, including communication with the care team and connection to appropriate services and resources.
• Facilitates warm handoffs and communication between patients, families, providers, the Nurse Case Manager, specialists, internal departments, and community partners to promote continuity of care and timely access to services.
• Follows up on missed or canceled appointments and assists patients in identifying and addressing barriers that contributed to missed care, rescheduling appointments, and reconnecting with appropriate services.
• Supports chronic disease management and self-management by reinforcing provider and Nurse Case Manager education, helping patients understand care plans and instructions, supporting individualized health goals, and encouraging healthy behaviors and adherence to recommended care.
• Provides patient education, basic motivational interviewing, and goal-setting support within the scope of the position, helping patients build confidence and skills to manage their health and work toward identified goals.
• Advocates for patients and assists with navigation of health and social service systems, including helping patients identify and utilize eligible programs, benefits, and community resources to improve access to care and promote self-sufficiency.
• Documents patient contacts, care plans, interventions, referrals, follow-up activities, and outcomes in accordance with Midtown Health Center policies and procedures and participates in tracking established program and performance measures.
• Build and maintain positive working relationships with patients, families, providers, staff, community organizations, and other members of the multidisciplinary care team to support effective communication and coordinated services.
• Provide community education and resource navigation by educating community members and partner organizations about Midtown Health Center (MHC) services, eligibility and available resources. Collaborate with community partners to facilitate referrals, coordinate access to services, and assist individuals in navigating healthcare and community resources to address barriers to care.
• Maintains current knowledge of community resources, services, programs, and eligibility requirements and shares relevant information with patients and the care team; participates in quality improvement activities and performs other duties as assigned.
• Performs other duties as assigned.

Duties 1 through 13 are designated as ADA Essential…