Los Angeles
Job DescriptionLocation: Skid-Row Downtown Los Angeles (CA) JWCH Mission Statement: The Mission of JWCH Institute is to improve the health status and well-being of under-served segments of the population of Los Angeles Area through the direct provision or coordination of health care, health education, services, and research. 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. Principal Responsibilities: • Collaborate with providers, managed care plans, the Housing Navigation Team, and community homeless service providers to ensure seamless care coordination for eligible patients., • Perform comprehensive case management services, including intake, assessment, personalized care plan development, plan implementation, subspecialty referrals, monitoring, and follow-up., • Connect members with essential social and support services, arranging referrals for specialized care (e.g., ophthalmology, behavioral health, podiatry, and nutrition), transportation, housing, and more., • Accompany patients/clients to appointments when necessary., • Advocate on behalf of members when engaging with healthcare professionals to ensure their needs are understood and addressed effectively., • Utilize motivational interviewing, trauma-informed care, and harm-reduction strategies to foster positive interactions and promote well-being., • Coordinate closely with clinical staff to establish well-structured discharge plans, ensuring a smooth transition for patients., • Monitor and encourage treatment adherence, including medication regimens, to support optimal health outcomes., • Provide health promotion and self-management training to empower patients in taking charge of their well-being., • Collect and input essential data for reporting purposes, ensuring the accurate completion of project activities and monthly reports as required by funding sources., • Engage in agency and community meetings to address patient needs and contribute to discussions related to case management concerns., • 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., • Collect data for comprehensive initial and ongoing assessments of patient needs, including functional status, housing, mental health, substance use, and education., • Regularly update Individual Service Plans (ISPs) during weekly client meetings and report progress at case conferences to ensure goals are met effectively., • Provide clients with appropriate referrals for a range of services, including HIV care, housing, food, transportation, benefits counseling, mental health services, and medical support., • 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., • Maintain confidentiality regarding client and employee information., • Participate in designated staff meetings, quality improvement initiatives, case conferences, and in-service trainings., • Medical Assistant certification preferred, with at least one year of case management experience., • High school diploma or GED required., • Minimum of two years of experience as a care coordinator, community health worker, or in a similar role., • Experience working with individuals with multiple chronic conditions, frequent ER visits or inpatient admissions, or those experiencing homelessness., • Proficiency in electronic health records (EHR) and data entry required., • Strong computer skills, including proficiency in Microsoft Word, Excel, and PowerPoint., • Excellent verbal and written communication skills., • Strong active listening and effective communication abilities., • Demonstrated empathy and compassion when working with clients facing challenging life circumstances., • Cultural competence and sensitivity to diverse social, economic, and cultural backgrounds., • Bilingual (English/Spanish) preferred *All JWCH, Wesley Health Centers workforce members are recommended to be fully vaccinated against COVID-19. Employee Benefits: At JWCH Institute, Inc., we believe in taking care of those who take care of others. If you work 30+ hours per week, you’ll enjoy competitive pay and a robust benefits package that includes: • Medical, Dental, Vision, • Monthly employer-sponsored allowance for assistance with health premiums., • Funded Health Savings Account (up to deductible) to assist with carrier-approved medical expenses., • Paid time off (vacation, sick leave) and 13 paid holidays., • 401(k) Safe Harbor Profit Sharing plan., • Mileage reimbursement., • Short- and long-term disability plans (LTD/STD). JWCH Institute, Inc + Wesley Health Centers is an Equal Opportunity and Fair Chance Employer. Monday through Friday 8:00am - 5:00pm