Case Manager - Grants Healing Wings

Description: The Case Manager assists patients and their family members with obtaining services or initiating referrals in an effort to eliminate personal or environmental barriers which may interfere with maximum benefits of health care. This position supports the provider and interdisciplinary team in facilitating and coordinating patient care through the continuum.

Typical Duties

• Utilizes advanced skills to assist in collaborating, developing, implementing, monitoring and evaluating the case management process.
• Performs psychosocial assessments to identify individualized needs in the areas of health, mental health, social support, addiction, financial resources, benefits, legal, language/culture, and employment.
• Communicates identified needs to other members of the health care team, serves as a patient advocate, and makes referrals to appropriate resources within the JPS Health Network and the community.
• Develops comprehensive care plans based on patient need and establishes goals in collaboration with the patient (including their family, significant others, and other social service providers when appropriate), aimed at increasing the level of functioning and self-sufficiency in all areas of life.
• Regularly reviews patient level of functioning, updates care plans, and maintains patient contact in accordance with their level of case management need.
• Aids with care coordination for patients with complex psychosocial needs, educates patients and their families regarding various care options, and ensures that the patient’s choices are incorporated into the plan.
• Follows-ups with patients and families to ensure that services provided are helpful, appropriate, and adequate.
• Develops and sustains long term working relationships with patients and families.
• Supports patients and providers with reviewing and completing various eligibility forms for medications, social programs, funding sources, durable medical equipment, etc. Provides informal supportive counseling to patients and families exhibiting complex issues directly impacting their care.
• Assists patients and families to cope with and manage life-changing diseases, death and dying, advanced directive education, disabilities, etc. Identifies and assesses patients at high risk for repeat hospital admissions and/or high utilization.
• Documents each component of the case management process and related activities in accordance with Texas Department of State Health Services (DSHS) Ryan White Service Standards and departmental guidelines.
• Attends and participates in activities related to compliance, audits, meetings, and required trainings.
• Performs other job related duties as assigned.