Case Manager

INTRODUCTION

Under the supervision of the Director of Social Services, the My Health GPS (MHGPS) Case Manager works with diverse populations with chronic health conditions. Primary responsibilities include, but are not limited to, developing person-centered trauma-informed case plans based on beneficiary needs, assisting beneficiaries in following through on established case plans, assessing and addressing Social Determinants of Health (SDOH), and assisting beneficiaries with enhancing social functioning, and improving their quality of life. The MHPGS Case Manager serves as planner, advocate, broker, and record keeper for assigned caseload. This is a hybrid position.

Major Duties/Essential Functions

Essential and other important responsibilities and duties may include, but are not limited to the following

• Provide wellness and chronic disease management for assigned caseload of MHGPS beneficiaries.
• Initiate outreach to MHGPS beneficiaries to educate them on available social services assistance in order to increase patient compliance with medical treatment to improve chronic medical conditions.
• Unitizes strength-based person-centered approach and motivational interviewing techniques to build rapport and engage beneficiaries into services to assist beneficiaries with addressing barriers to care.
• Complete biopsychosocial assessments and update annually.
• Develop person-centered trauma-informed case plans to ensure services are responsive to the individual beneficiary.
• Complete follow up on case plans at 90 day intervals, and update as necessary based on changing beneficiary needs.
• Respect, and acknowledge cultural diversity of all of patients and staff, as well as integrate patients’ culture and values into interactions, service provision, and case plans.
• Develops a therapeutic working relationship with beneficiaries.
• Assess each beneficiary for Social Determinants of Health (SDOH) by completing screening tool every 6 months.
• Work with beneficiary to address barriers to medical care and to improve medication adherence and treatment compliance.
• Link beneficiaries to resources based on identified needs identified during SDOH screening.
• Provides regular follow up to all clients to ensure successful linkage to, and utilization of, community resources and/or in-house services.
• Use crisis intervention and de-escalation skills to address crisis as necessary.
• Coordinates with MHGPS team and MCOs to share information regarding beneficiaries’ status
• Provides solution focused and problem solving with challenging beneficiary situations.
• Accurately document all beneficiary encounters and complete required MHGPS and Social Services forms within established time frame.
• Assess for, and assist with insurance and other social services benefits as necessary.
• Maintain professional relationship and appropriate boundaries.
• Participates in professional development opportunities and regular supervision.
• Attends regular departmental, health center, and agency meetings, activities, and events.
• Performs other duties as assigned.
  
  

Minimum Qualifications

• Bachelor’s degree Social Work*, Psychology, or related Human Services field required
• 2 years of experience working in a community health or social services agency required. Internship experience considered.
• Experience working as a case manager required.
• Experience working with vulnerable and at-risk population required.
• Experience working in under-resourced communities required.
• Outreach experience and knowledge of community resources required.
• Experience managing chronic medical conditions preferred.
• Applicants with a bachelor’s degree in social work (BSW) must have an active DC social work license to work in the District of Columbia. Applicants applying for reciprocity are welcome to apply, but must receive their DC social work license within the first 90 days of employment.
  
  

OR

• Master’s degree in Social Work, Psychology, or related Human Services field preferred.
• Minimum of 1 experience working in a community health or social services agency required. Internship experience considered.
• Experience working with vulnerable and at-risk populations preferred.
• Experience working as a case manager required.
• Experience working with vulnerable and at-risk population required.
• Experience working in under-resourced communities required.
• Outreach experience and knowledge of community resources required.
• Experience managing chronic medical conditions a plus.
  
  

KNOWLEDGE, SKILLS, AND ABILITIES

• Knowledge of resources and social support services in the District of Columbia
• Familiarity with homeless and housing services
• Strong oral and written communication skills required.
• Good interpersonal skills required.
• Knowledge of human behavior.
• Must be a skillful interviewer, able to ask questions and effectively use interview skills to elicit needed information from clients.
• Must be a skillful listener, able to understand the meaning of client's statements.
• Must be a skillful observer, able to record the client's behavior and needs.
• Must be a skillful negotiator, able to reach definitive agreements with clients and service providers.
• Must be able to work well with interdisciplinary teams.
• Ability to prioritize and problem solve to maintain a case load.
• Strong organizational skills.
• Work experience with a challenging population preferred.
• Ability to type, and use electronic health records software program.
• Proficient in most products of Office 365 (Word, Excel, Power Point and Teams)
  
  

SUPERVISORY CONTROLS

This position reports directly to the Director of Social Services.

GUIDELINES

The position abides by all rules and regulations set forth by applicable licensing and regulatory bodies and the UHC policies and procedures.

PERSONAL CONTACTS

The position requires contact with staff at all levels throughout the organization. There are also external organization relationships that may be part of the work of this individual.

PHYSICAL EFFORT AND WORKING CONDITIONS

Refer to attached ADA Checklist.

Other Significant Facts

The incumbent must be able to balance the needs of diverse constituencies on a daily basis.

RISKS

The position involves everyday risk and discomforts, which require normal safety pre-cautions typical of such places as offices, meetings, training rooms, and other UHC health Care Sites. The work area is adequately lit, heated, and ventilated. All medical services shall be provided according to medically accepted community standards of care. The employee shall provide evidence of recent (within the past twelve (12) months) health assessment that includes a PPD and/or chest x-ray results. COVID-19 and Flu vaccinations required.

The statements contained herein describe the scope of the responsibility and essential functions of this position, but should not be considered an all-inclusive listing of work requirements. Individuals may perform other duties as assigned including work in other areas to cover absences or relief to equalize peak work periods or otherwise balance the workload.

RISKS

The position involves everyday risk and discomforts, which require normal safety pre-cautions typical of such places as offices, meetings, training rooms, and other UHC health Care Sites. The work area is adequately lit, heated, and ventilated. All medical services shall be provided according to medically accepted community standards of care. The employee shall provide evidence of recent (within the past twelve (12) months) health assessment that includes a PPD and/or chest x-ray results.

The statements contained herein describe the scope of the responsibility and essential functions of this position, but should not be considered an all-inclusive listing of work requirements. Individuals may perform other duties as assigned including work in other areas to cover absences or relief to equalize peak work periods or otherwise balance the workload.