Care Manager - Community Liaison - Outreach

Responsibilities

• Conduct comprehensive client assessments to identify cognitive, medical, functional, behavioral, and social support needs.
• Develop, implement, maintain, and update individualized electronic records and care plans in collaboration with clients, caregivers, and the interdisciplinary care team.
• Maintain timely and complete documentation of client interactions, care plans, assessments, progress notes, and billable services within the electronic health record (EHR).
• Perform caregiver assessments to identify caregiver needs, provide education, and connect clients and families with appropriate community resources and support services.
• Provide ongoing care management services for clients in accordance with CMS guidelines.
• Advocate for clients by helping them navigate the healthcare system and access appropriate medical, behavioral health, and community services.
• Conduct routine client outreach to monitor health status, medication adherence, treatment compliance, and progress toward care plan goals.
• Identify barriers to care and develop interventions to improve patient engagement, self-management, and health outcomes.
• Facilitate communication among clients, caregivers, and other members of the care team to ensure continuity of care.
• Track and document care management time to support CMS billing and reimbursement requirements.
• Ensure compliance with CMS GUIDE, CCM, HIPAA, Medicare documentation standards, and applicable organizational policies and procedures.
• Monitor quality measures and contribute to initiatives that improve client outcomes, patient satisfaction, and program performance.
• Develop and maintain positive working relationships with community organizations, healthcare providers, senior centers, social service agencies, faith-based organizations, and other community partners to strengthen referral networks and access to services.
• Represent JFCS and the care management program at community events, health fairs, senior programs, educational presentations, provider meetings, and other outreach activities.
• Engage in proactive community outreach to educate older adults, caregivers, professionals, and community organizations about available JFCS programs, care management services, and community resources.
• Identify potential clients and referral opportunities through community outreach and establish connections with the care management team and intake/referral processes.
• Cook up with internal programs and external community partners to facilitate referrals, promote continuity of services, and address gaps in resources for older adults and their caregivers.
• Coordinate with internal programs and external community partners to facilitate referrals, promote continuity of services, and address gaps in resources for older adults and their caregivers.
• Provide presentations and educational materials on care management, aging-related services, benefits, healthcare navigation, and other relevant topics to community and professional audiences.
• Track and report community outreach activities, referral sources, partnership development, and other program engagement metrics as assigned.
• Identify emerging community needs, service gaps, and barriers affecting older adults and communicate findings to leadership to support program development, growth, and continuous improvement.
• Participate in team conferences, trainings, weekly supervision, department meetings, and other staff meetings as assigned.
• Perform other duties as assigned by the direct supervisor.

Requirements

• Bachelor's degree in social services, human services, health care, or a related field required; Master's degree preferred.
• Minimum of two (2) years of experience in care management, case management, chronic disease management, population health, or a related healthcare setting.
• Experience working with older adults.
• Experience developing relationships with community organizations, healthcare providers, referral sources, or other external partners preferred.
• Experience conducting community outreach, presentations, education, or engagement activities preferred.
• Excellent communication, organizational, relationship-building, and critical thinking skills.
• Ability to work independently while collaborating effectively with interdisciplinary teams and community partners.
• Proficiency with Electronic Health Records (EHR) and Microsoft Office applications.

Other Requirements

• Successful completion of criminal background check, child abuse clearance, and FBI fingerprinting.
• Ability to work at multiple JFCS locations, in client homes, and in community settings.
• Driving is required for assigned duties; the employee must maintain a valid driver's license, proof of insurance, and a safe driving record.