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Works with patients and their families to utilize health care resources, social services and community resources appropriately to optimize and improve their health status.
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Responsible for developing a resource and referral list within the community, as well as establishing on-going relationships with social service providers, drug and alcohol programs, mental health providers, schools, child care, employment / training programs and other community sources of support.
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Responsible for developing a process for identification and referral of patients.
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Plans and develops a tracking and reporting system for the case management program.
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Creates and reviews referral agreements and protocols for referrals.
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Identifies clinic patients who are chronically ill or have multiple diagnoses and who indicate a willingness to participate in this program.
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Assesses the psycho-social needs of each patient (and family) and his or her coping and adaptive abilities, formal and informal support-systems, and self care abilities.
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Determines the barriers each patient faces (literacy, language, income, etc) and helps the patient develop a plan to overcome them.
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Establishes baseline data on the health status and utilization patterns of these patients.
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Enrolls patients in early intervention program if necessary.
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Facilitates and promotes effective communication between the patient and the primary care provider and collaborates with the provider in the development of an effective patient education program.
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Meets regularly with the clients and assists them in fulfilling recommendations for their plan of care including, but not limited to: explanation of special instructions, assistance with transportation, translation, problem resolution and provision of diagnosis related health education when needed.
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Acts as liaison and facilitator between client and interdisciplinary care team.
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Assists with problem solving and decision making when necessary.
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Provide information to other agencies as appropriate.
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Communicates regularly with providers, nurse managers and other medical staff.
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Facilitates access to financial coverage for needed care:Medi-Cal, Indigent Patient Drug Program, etc.
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Coordinates and participates in Quality Assurance activities.
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Attends and coordinates chart review and case conference with staff members and other involved community providers.
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Adherence to ODCHC’s attendance policy.
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Other duties and responsibilities as designated by supervisor.
QUALIFICATIONS:
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Ability to work as a member of a team in order to solicit input from other affected departments or individuals, communicate pertinent information to other team members, and support team decisions.
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Ability to communicate effectively and exercise sound and responsible judgment.
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Excellent interpersonal skills, written and verbal.Ability to establish constructive working relationships with all levels of management and employees in a staff of varied and diverse backgrounds.
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Ability to handle difficult or confrontational situations in a calm, consistent, and equitable manner.
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Ability to read, analyze, and interpret business periodicals, professional journals, technical procedures, and governmental regulations.
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Ability to effectively represent the Clinic’s interests in the community; maintaining effective working relationships among public, private and professional groups.
EDUCATION and/or EXPERIENCE:
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Masters degree in Social Work.
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Must have at least one year of experience in case management nursing and/or familiarity with community clinic settings.
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Bi-lingual ability in Spanish preferred.
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Familiarity with the community and the resources that are available locally preferred.
SUPERVISORY RESPONSIBILITIES:
NONE
PHYSICAL REQUIREMENTS
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Speaking and hearing sufficient to communicate effectively by phone or in person, at normal volumes.
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Vision adequate to read correspondence, computer screen, forms, etc.
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Good manual dexterity.
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Ability to sit for extended periods of time.
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Must have valid California Driver’s license and a reliable form of transportation.