Bilingual Care Manager

HeartShare St.Vincents is looking for a Care Manager for our Integrated Health Department! The Care manager has overall day to day responsibility for coordinating the activities of the care team for clients with complex medical and/ or psychiatric co-morbid conditions and for facilitating clients’ access to the full range of medical and psychosocial services in an efficient and effective manner.

Essential Functions and Primary Responsibilities of Position:

• Use positive approaches when handling difficult situations.

• Remains flexible and adapts to change.

• Serves as a role model for program participants.

• Remains sensitive and responsive to cultural differences of program participants and staff.

• Participates in multi-disciplinary case conferences and projects, demonstrating team spirit and ability to work with other community-based organizations to meet clients’ needs.

• Works closely with the interdisciplinary care team including PCP, psychiatrist, therapist, residential services, substance abuse treatment program, ACT Team, etc.

• Provides input to providers/client/family for written individualized care plans.

• In conjunction with the client, identifies potential barriers to care and resolutions to those barriers; outreaches to clients who have not met treatment goals to resolve barriers/adjust goals when possible.

• Evaluate medication compliance and assess potential barriers to adherence; ensure medication reconciliation is current

• Receives alerts for ER admissions of assigned clients, visits clients during admission and participates actively in discharge planning and care transition activities; and contacts clients on the day of discharge from client services and ER or within 24 hours

• Outreaches to clients to facilitate keeping scheduled appointments; arranges for metabolic and periodic preventive screening, per evidence-based guideline standards

• Coordinates services between client and extended care team providers to ensure that integrated care plan is fully implemented

• Regularly reviews client information from care team members to identify clients requiring outreach and engagement,and identifies quality of care issues and refers appropriately.

• Provides or arranges for provision of self-management/ wellness education, peer and other support groups in the language that the client/family prefers.

• Reviews benefits, entitlements, housing with the client/family and assist in the application process. Follows up as necessary to ensure services are approved.

• Complete outreach to clients to enroll into services if there is a decrease in current caseload.

• Adhere to all government and funder regulations

• Performs other job-related duties as assigned, consistent with the scope, responsibilities, and level of the position, and in compliance with applicable laws, regulations, and organizational policies.