The Healthy Families Case Manager provides intensive case management services to Zufall Health primary care patients and their families as part of a research pilot program in collaboration with Penn Medicine. The Case Manager assists eligible families in accessing clinical and social services, including appropriate health screenings, diagnostic testing, primary medical, oral, and behavioral health care, support services, and treatment to achieve improved health outcomes. The Case Manager focuses on needs and barriers (such as financial, cultural, language, and insurance) that prevent patients from achieving improved health outcomes. The Case Manager plays an integral role in the care coordination and management of patients and is a key member of the Care Team. Travel is expected throughout Middlesex and Mercer Counties to meet with patients and attend community meetings. The Case Manager reports to the Clinical Director at Plainsboro and is in the medical department.

Essential Functions, Duties, and Responsibilities

• Works as part of the Care Team to identify patients in need of services and communicates with the patient’s healthcare team of progress of case and of unidentified needs. Target population is primary care patients with a least one minor who is 12 or older in their household and at least one family member has an A1C level >7%, 4 or more ER visits in the past 12 months, or uncontrolled hypertension. 
• Screens patients referred by the care team for program eligibility and enrolls if indicated and patient consents. 
• Provides in-reach to Zufall Health Center staff to encourage referrals. 
• Provides comprehensive case management assessment that includes life domains such as housing, finances, transportation, legal services, vocational, employment, health and behavioral healthcare and family strengths and needs. 
• Conducts intake process and determines clinical and social needs and coordinates plan of care for each patient. 
• Provides ongoing, intensive case management to all program participants based on their identified areas of need. 
• Maintains regular contact with program participants: two times a month at minimum by phone/video or face-to-face, more often as indicated by case management assessment and family care plan. When participants consent, in-community and/or home visits should occur at least every three months. 
• Conducts interviews and health surveys at enrollment, 3 month, 6 month, 9 month, and 12 month intervals. 
• Schedules and coordinates appointments and follows up on missed appointments, rescheduling as needed. Contacts patients who are overdue for return visits. Monitors patient participation in follow-up care. 
• Assists patients with arrangements for transportation, interpretation and translation, and other barriers to attending appointments and accessing care. 
• Assists patients with completion of medical and prescription forms and request to other providers and agencies. 
• Engages family with the plan of care with permission of patient whenever available or appropriate. 
• Enters interventions done and plans in electronic health record via telephone encounter or case management notes and other HIPPA-compliant platforms as needed. Scans documents related to patient care into their electronic health record. 
• Facilitates patient enrollment into appropriate providers, programs, services, or organizations as needed. 
• Assists patients with applications for Charity Care at local hospitals, Medicaid, NJ Family Care and other financial support benefits or insurances as appropriate. 
• Increases patients’ sense of empowerment in their ability to navigate the healthcare system. Provide support, empathy, and guidance to patients related to their healthcare journey. 
• Acts as advocate for patients with community organizations and governmental agencies. 
• Establishes and cultivates excellent external referral relationships with community-based organizations who are referring or who will be referred to, as appropriate.
• Develops and maintains a referral resource list.
• Tracks program enrollment, levels of services provided, collecting data, and program activities. 
• Uses evidence-based practices in service delivery to implement the program, develop processes, track receipt of services and referrals, track required health outcomes, generate reports and conduct quality assurance and performance improvement activities 
• Attends trainings related to care coordination. 
• Works to meet program target objectives with key personnel. 
• Other duties as assigned. 

Knowledge, Skills and Abilities

• Excellent knowledge of the health and psychosocial issues of families with complex medical and social needs
• Excellent knowledge of available community services and resources
• Excellent communication and interpersonal skills
• Bilingual Spanish/English required
• Ability to interact well with patients, Zufall staff, and community partners and organizations
• Ability to work with an interdisciplinary team
• Demonstrate effective follow-through with all tasks
• Ability to maintain high level of confidentiality
• Ability to work independently and complete assignments in a timely manner
• Working knowledge of Zufall policies and procedures, and adoption of mission and values of Zufall
• Learn and apply trauma informed care principles within the scope of the position 
• Maintains calm demeanor and empathetic, patient-centered orientation even under stressful circumstances 
• Knowledge of Microsoft Office and use of electronic medical records

Education, Training and Experience 

• Bachelor’s Degree in social work, public health, or related field 
• Minimum of two years’ experience in clinical or social service setting
• Experience working with patients and families with unmet social needs
• Experience with research, data collection and analysis