ECM Case Manager-REACH Program

Hill Country Health and Wellness Center

Job Description

Job Title: Enhanced Care Management- Case Manager REACH Program

Department:Community Programs

FLSA Status: Non-Exempt

Reports To:ECM Program Manager

Hours:M-F, 8am-5pm, varies

POSITION SUMMARY:

Hill Country Health and Wellness is identified as a Transitions Clinic Network Program. This position is best served by a case manager with a history of incarceration and will be working with an integrated team.

The REACH ECM Case Manager will provide outreach, advocacy, navigational, and case management services to individuals that have recently been released from incarceration with chronic medical conditions, including those affected by psychiatric and/or substance use disorders. A shared history with the re-entry population helps with engagement and building trust, which leads to improved health outcomes for patients.

The ECM-REACH Case Manager works as part of a team to support participants in learning skills to make behavioral changes to improve their health and wellness.Under minimal supervision, work independently and in close collaboration with Hill Countrys medical staff, behavioral health staff, case management staff and other community agencies to provide outreach, navigational services and direct case management services to maximize health outcomes.Learns and uses a harm reduction approach to promote change.

ESSENTIAL DUTIES AND RESPONSBILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Other duties may be assigned which may become essential to the position.

Under the supervision of the ECM Manager and in collaboration with the Transitions Clinic Network team, the ECM-REACH Case Manager is responsible for maintaining the REACH caseload by performing the following essential job functions:

• Recruits individuals by conducting outreach activities in the community.
• Provides support, empowerment, education and case management services to recently released individuals.
• Advocates for participants as needed to access services within the community.
• Serves as liaison between the professional staff and the community, including developing relationships with various stakeholders in the re-entry community.
• Conducts periodic assessments of participants strengths, basic needs, social determinants and any barriers to care. Identifies problem areas that affect daily functioning and are barriers to engage in recommended services.
• Provides education to participants about the health care system and facilitates access to services.
• Collaboration with community resources for referrals and coordination of services.
• Maintain close communication with medical, behavioral health and other support staff as needed to meet participants needs.
• Work closely with participants to develop individualized care plans to meet individual needs.
• Collaborates with medical and behavioral health to provide health and behavioral interventions.
• Advocate for participants as needed to obtain housing.
• Make referrals for needed services and facilitate access to community resources.
• Assists participants in utilization of services, maintains follow up contacts and coordination of care.
• Assist in arranging appointments as needed to support access to care.
• Provides education of chronic health conditions, substance/alcohol related disorders and standards of care and self-management of their conditions.
• Provides education and training of substance/alcohol related disorders, including but not limited to substance refusal skills, relapse prevention and recovery planning.
• Provides brief intervention to address alcohol/substance use, and/or behaviors to assist patients to gain strategies to overcome obstacles that interfere with the recovery process.
• Continually monitor and evaluate patients progress on goals, treatment and/or care plans.
• Adheres to strict boundaries and professional ethics in the care of others.
• Maintains accurate and timely documentation of all interactions, including telephone calls.
• Meets regularly for clinical supervision for consultation with clients and additional support.
• Attends required TCN Program meetings and work in collaboration with partners of the TCN network.
• Participate in ongoing education and training for professional development.
• Attend program-related community, coalition and committee meetings as assigned by supervisor
• May transport ambulatory participants to medical, behavioral health appointments as well as other social service agencies.
• Assists to gather and evaluate data concerning the TCN Program.
• Performs other duties as assigned.

Minimum Qualifications

• History of prior incarceration.
• High School Diploma or GED required.
• Experience with assessment, treatment planning, conducting interviews and counseling.
• Excellent oral and written communication skills.
• Demonstrates excellent attendance, reliability and dependability.
• Able to work flexible work schedule (may include some evenings and weekends).
• Comfortable working with culturally diverse populations.
• Willingness to work in various environments, including home visits, prisons/jail setting, street outreach, and homeless encampments etc.
• Ability to work with a team of professionals and have the ability to implement team strategy approaches to work assignments.
• Be familiar with the Harm Reduction Model.
• Ability to work with computers and the necessary software programs to perform all duties.
• Valid California drivers license and excellent driving record

Preferred Qualifications:

• Experience working with formerly incarcerated individuals.
• Knowledge and experience working with the criminal justice systems
• Motivational Interviewing skills and knowledge of the stages of change.
• Experience working with people with SUD, mental health and/or chronic health conditions and co-occurring disorders.
• Experience working in collaboration with SUD treatment programs, health care systems and community-based organizations.

BEHAVIORAL STANDARDS:

• Adhere to Policies and Procedures
• Participate in team systems
• Perform duties ethically
• Maintain patient confidentiality
• Demonstrate ability to re-prioritize duties as needs arise
• Use time efficiently
• Be responsible for co-workers and patient satisfaction
• Display flexibility in accepting, changing, and carrying out assignments
• Maintain a neat, clean, and safe work environment throughout the facility
• Perform duties with kindness in a quality manner

QUALIFICATIONS:

The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Language Ability:

Must have intermediate level language skills. Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before individuals, groups or employees of organization.

Math Ability:

Must have basic math skills. Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percentages.

Reasoning Ability:

Must have intermediate level reasoning skills. Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.

Computer Skills:

To perform this job successfully, an individual should have knowledge basic working knowledge of Windows operating systems, Microsoft Office Suite - Word, Excel, Outlook, and Internet browsers.

Equipment Skills:

Must have good working knowledge of standard medical equipment

WORK ENVIRONMENT:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The position requires work to be performed in various work environments. This may include indoor/outdoor and medical office environment. Employee will occasionally be exposed to fumes or airborne particles, outdoor weather conditions, and may occasionally exposed to risk of electrical shock. The noise level in the work environment is usually moderate with normal business office, computer, printer and medical equipment noises. In addition performance of duties will include outreach in the community and working in various environments.

PHYSICAL DEMANDS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, employees will regularly use hands to finger, handle or feel, and talk or hear. Employees will frequently sit and reach with hands or arms. Employees will occasionally stand, walk, balance, stoop, kneel or crouch, and smell. Employee will frequently lift and/or move up to 10 pounds, and occasionally lift and/or move up to 25 pounds. Employee must use close vision, distance vision, color vision, peripheral vision, depth perception and ability to focus.