Older Adult Services Case Manager

Essential Functions, Duties, and Responsibilities

• Works as part of the Care Team to identify patients in need of services and communicates with the patient’s healthcare team of progress of case and of unidentified needs.
• Provides in-reach to Zufall Health Center staff to encourage referrals.
• Provides outreach to community organizations to encourage referrals.
• Conducts intake process and determines clinical and social needs and coordinates plan of care for each patient.
• Provides ongoing, intensive case management to all program participants based on their identified areas of need.
• Maintains regular contact with program participants including phone/video communication at least once a month, in-community visits every three months, and home visits every six months.
• Schedules and coordinates appointments and follows up on missed appointments, rescheduling as needed. Contacts patients who are overdue for return visits. Monitors patient participation in follow-up care.
• Affords assistance to patients with arrangements for transportation, interpretation and translation, and other barriers to attending appointments and accessing care. In the older adult population, barriers may include but are not limited to dementia, mobility issues, low motivation related to depression, and inadequate social support systems.
• Affords assistance to patients with completion of medical and prescription forms and request to other providers and agencies.
• Affords engagement of caregiver(s)/family with the plan of care with permission of patient whenever available or appropriate.
• Enters interventions done and plans in electronic health record via telephone encounter or case management notes. Scans documents related to patient care into their electronic health record.
• Affords assistance to medical providers with contacting patients to discuss results and additional procedures or recommendations for other services such as clinical pharmacy services.
• Educates patients about what, why and how tests are being done. Instructs patients with preparation for all procedures.
• Facilitates patient enrollment into appropriate providers, programs, services, or organizations as needed.
• Affords assistance to patients with applications for Charity Care at local hospitals, Medicaid, NJ Family Care and other financial support benefits or insurances as appropriate.
• Increase patients’ sense of empowerment in their ability to navigate the healthcare system. Provide support, empathy, and guidance to patients related to their healthcare journey.
• Acts as advocate for patients with community organizations and governmental agencies.
• Affords assistance in establishing and cultivating excellent external referral relationships with community-based organizations who are referring or who will be referred to, as appropriate. Develops and maintains a referral resource list specific to the older adult population.
• Affords assistance with tracking program enrollment, levels of services provided, collecting data, and tracking program activities and expenses.
• Attends continuing education trainings related to older adults.
• Coordinates with Zufall’s Outreach and Enrollment team to complete at least four outreach/community education activities annually.
• Works to meet program target objectives.
• Other duties as assigned.

Education, Training and Experience

• Bachelor’s Degree in social work or related field; MSW preferred
• Minimum of two years’ experience in clinical or social service setting
• Experience working with older adults preferred