Case Manager

Position Purpose: 

The Case Manager provides comprehensive case management services to eligible patients, including high utilizers of services, individuals and families experiencing homelessness, and adults with serious mental illness and/or substance use disorders. Reporting to the Program Manager, the Case Manager is responsible for assessing clients' needs, developing tailored care plans, and coordinating a range of resources to enhance their well-being. This position collaborates closely with a multidisciplinary team to facilitate effective communication, monitor progress, and advocate for optimal outcomes.

Program Population:

The Pathway Home Housing Project is a HFH funded program, operated by JWCH. The Team consist of a cohesive team of MSW, case managers, site monitors and other professionals who collaborate to provide housing and critical services to People Experiencing Homelessness (PEH) and those who have previously experienced homelessness. The clients/residents may come with behavioral and/or substance abuse issues. The program utilizes the Harm Reduction Model and we “do whatever it takes” to encourage success of the client. 

Principal Responsibilities: 

1. Collaborate with providers, managed care plans, the Housing Navigation Team, and community homeless service providers to ensure seamless care coordination for eligible patients.
2. Perform comprehensive case management services, including intake, assessment, personalized care plan development, plan implementation, subspecialty referrals, monitoring, and follow-up.
3. Connect members with essential social and support services, arranging referrals for specialized care (e.g., ophthalmology, behavioral health, podiatry, nutrition), transportation, housing, and more.
4. Accompany patients/clients to appointments when necessary.
5. Advocate on behalf of members when engaging with healthcare professionals to ensure their needs are understood and addressed effectively.
6. Utilize motivational interviewing, trauma-informed care, and harm-reduction strategies to foster positive interactions and promote well-being.
7. Coordinate closely with clinical staff to establish well-structured discharge plans, ensuring a smooth transition for patients.
8. Monitor and encourage treatment adherence, including medication regimens, to support optimal health outcomes.
9. Provide health promotion and self-management training to empower patients in taking charge of their well-being.
10. Collect and input essential data for reporting purposes, ensuring the accurate completion of project activities and monthly reports as required by funding sources.
11. Engage in agency and community meetings to address patient needs and contribute to discussions related to case management concerns.
12. 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.
13. Collect data for comprehensive initial and ongoing assessments of patient needs, including functional status, housing, mental health, substance use, and education.
14. Regularly update Individual Service Plans (ISPs) during weekly client meetings and report progress at case conferences to ensure goals are met effectively.
15. Provide clients with appropriate referrals for a range of services, including HIV care, housing, food, transportation, benefits counseling, mental health services, and medical support.
16. 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.
17. Maintain confidentiality regarding client and employee information.
18. Participate in designated staff meetings, quality improvement initiatives, case conferences, and in-service trainings.
19. Adhere to all organizational safety policies, procedures, and regulatory requirements to ensure a safe environment for patients, staff, and visitors.
20. Participate in required safety and compliance trainings and apply learned practices in daily work activities.
21. Identify, report, and help mitigate unsafe conditions, incidents, or hazards in the workplace.
22. Use equipment, tools, and supplies safely and responsibly in accordance with organizational and regulatory standards.
23. Maintain awareness of infection control, occupational health, and emergency preparedness procedures appropriate to the role.
24. Safely operate a personal or company vehicle to conduct home visits, community outreach, and client transport as needed.
25. Maintain a valid driver’s license and a clean driving record in accordance with organizational policy
26. Perform other duties as assigned.