Bilingual Community Health Case Manager

JOB SUMMARY:

The Case Manager, Community Health at the City of Frederick’s Federally Qualified Health Center (FQHC) will provide comprehensive case management and case coordination services to patients, particularly those facing barriers to accessing healthcare. The Case Manager will work closely with healthcare providers, other Housing and Human Services Case Managers, and community organizations to ensure that patients—especially those with chronic health conditions or complex care needs—receive the medical care, social services, and support they need to achieve optimal health outcomes.

This role will focus on addressing social determinants of health such as housing instability, food insecurity, transportation challenges, and access to medications or healthcare.

• Conducts intake assessments for new patients to evaluate their physical, behavioral, and social needs, including health conditions, living situation, access to food and transportation, and financial resources.
• Develops and implements individualized care plans in collaboration with healthcare providers, ensuring patients receive appropriate services related to medical care, mental health, and social services.
• Coordinates patient care by facilitating referrals to specialists, mental health providers, substance abuse services, and other necessary healthcare services.
• Helps patients navigate the healthcare system, including assistance with scheduling appointments, understanding medical instructions, and connecting to resources like Medicaid or other insurance programs.
• Educates patients about their conditions, treatment options, and self-management strategies, ensuring they understand how to effectively manage their health.
• Identifies and addresses social determinants of health affecting patients, including housing instability, food insecurity, transportation barriers, and lack of access to healthcare services.
• Connects patients with other HHS programs and local community resources such as food pantries, housing assistance programs, transportation services, and financial assistance programs.
• Provides regular follow-up and check-ins with patients to track their progress, ensure compliance with treatment plans, and addresses any new barriers to care.
• Assists patients with navigating the complexities of public health insurance (e.g., Medicaid) and community‑based health programs.
• Maintains accurate, confidential case records for all patients in accordance with FQHC policies and HIPAA regulations.
• Documents all patient interactions, progress notes and follow‑up activities in the electronic health record (HER) system.
• Reports on patient outcomes and case management activities to supervisors and funding agencies, as required.
• Performs other duties as assigned.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Any combination of training and experience which demonstrates ability to perform the duties and responsibilities as described; a typical qualifying background would include coursework in social work, nursing, public health, health education, or a related field.
• Two (2) years of experience in healthcare case management, community health, or social services, preferably in an FQHC or clinic setting.
• Experience with underserved populations and familiarity with social determinants of health is highly desirable.

• Vehicle Operator’s license with satisfactory…