Case Manager

• Perform comprehensive case management services, including intake, assessment, personalized care plan development, plan implementation, subspecialty referrals, monitoring, and follow-up.
• Connect members with essential social and support services, arranging referrals for specialized care (e.g., ophthalmology, behavioral health, podiatry, and nutrition), transportation, housing, and more.
• Accompany patients/clients to appointments when necessary.
• Advocate on behalf of members when engaging with healthcare professionals to ensure their needs are understood and addressed effectively.
• Utilize motivational interviewing, trauma-informed care, and harm-reduction strategies to foster positive interactions and promote well-being.
• Coordinate closely with clinical staff to establish well-structured discharge plans, ensuring a smooth transition for patients.
• Monitor and encourage treatment adherence, including medication regimens, to support optimal health outcomes.
• Provide health promotion and self-management training to empower patients in taking charge of their well-being.
• Collect and input essential data for reporting purposes, ensuring the accurate completion of project activities and monthly reports as required by funding sources.
• Engage in agency and community meetings to address patient needs and contribute to discussions related to case management concerns.
• Participate in weekly case conferences with PCPs, clinical supervisors, and peers to facilitate collaborative problem solving for client-related challenges and ensure the delivery of high-quality case management services.
• Collect data for comprehensive initial and ongoing assessments of patient needs, including functional status, housing, mental health, substance use, and education.
• Regularly update Individual Service Plans (ISPs) during weekly client meetings and report progress at case conferences to ensure goals are met effectively.
• Provide clients with appropriate referrals for a range of services, including HIV care, housing, food, transportation, benefits counseling, mental health services, and medical support.
• Verify clients' eligibility for public assistance programs and guide them through the necessary steps to access programs such as HWLA, Medi-Cal, SSI, GR, and housing options.
• Maintain confidentiality regarding client and employee information.
• Participate in designated staff meetings, quality improvement initiatives, case conferences, and in-service trainings.
• Perform other duties as assigned.

• High school diploma or GED required.
• Minimum of two years of experience as a care coordinator, community health worker, or in a similar role.
• Experience working with individuals with multiple chronic conditions, frequent ER visits or inpatient admissions, or those experiencing homelessness.
• Proficiency in electronic health records (EHR) and data entry required.
• Strong computer skills, including proficiency in Microsoft Word, Excel, and PowerPoint.
• Excellent verbal and written communication skills.
• Strong active listening and effective communication abilities.
• Demonstrated empathy and compassion when working with clients facing challenging life circumstances.
• Cultural competence and sensitivity to diverse social, economic, and cultural backgrounds.
• Bilingual (English/Spanish) preferred

• Medical, Dental, Vision
• Monthly employer-sponsored allowance for assistance with health premiums.
• Funded Health Savings Account (up to deductible) to assist with carrier-approved medical expenses.
• Paid time off (vacation, sick leave) and 13 paid holidays.
• 401(k) Safe Harbor Profit Sharing plan.
• Mileage reimbursement.
• Short- and long-term disability plans (LTD/STD).
• Life insurance policy & AD&D, and more!

JWCH Institute