Care Manager, Non-Medical Drivers of Health, Food Market (4662)

Key Responsibilities:

• Deliver relevant case management and resource navigation services for high-risk children and/or pregnant women referred to WFM's patient-choice food rx program

• Assists in providing a clean, safe, efficient and welcoming environment in Waco Family Medicine’s food pantry and its facility

• Assists with the receiving of food items, stocking of food items, and organization of the pantry space as needed.

• Conduct required patient/neighbor intake and data entry

• Collaborate with internal teams on continuous improvement efforts for the patient-choice food rx program and CPW service line

• Assist with the provision of Nutrition Education training to patient/neighbors

• Assess and respond to psychosocial, financial, NMDOH, functional, cognitive and medical needs.

• Identify and address gaps in patient care through visits to the Food Market; Identify and utilize patient’s systems of support and facilitators for reaching health goals.

• Conduct comprehensive psychosocial needs assessments, screen and refer to appropriate agencies or internal programs for NMDOH needs.

• Develop individualized care plans for eligible care management patients focusing on short and long-term medical, behavioral health, and NMDOH goals of care.

• Assist patients in navigating the healthcare system and Waco Family Medicine’s food pantry.

• Apply knowledge of community resources to address care gaps or improve quality of life conditions.

• Full-time, 40 hours per week with a work schedule of Monday – Thursday with evening hours, and scheduled Saturdays.

OTHER DUTIES

• As assigned by supervisors.