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INTRODUCTION

The LAG-USC Recuperative Care Program is a 24 hours a day, 7 days a week program/facility.

Position Purpose:

The Case Manager provides comprehensive case management services to eligible patients, including high utilizers of services, individuals and families experiencing homelessness, and adults with serious mental illness and/or substance use disorders. Reporting to the Program Manager, the Case Manager is responsible for assessing clients' needs, developing tailored care plans, and coordinating a range of resources to enhance their well-being. This position collaborates closely with a multidisciplinary team to facilitate effective communication, monitor progress, and advocate for optimal outcomes.

Program Population:

LAG Recuperative Care Center is an Interim Housing program that assists homeless, medically compromised individuals in recovering and improving their health conditions. These individuals may also experience mental health and substance abuse issues, which can lead to behaviors such as yelling, cursing, and outbursts of anger. The role of each staff member at LAG RCC is to assist the client in overcoming barriers and increasing coping skills to reduce negative behaviors.

Principal Responsibilities:

• Collaborate with providers, managed care plans, the Housing Navigation Team, and community homeless service providers to ensure seamless care coordination for eligible patients.
• Perform comprehensive case management services, including intake, assessment, personalized care plan development, plan implementation, subspecialty referrals, monitoring, and follow-up.
• Connect members with essential social and support services, arranging referrals for specialized care (e.g., ophthalmology, behavioral health, podiatry, nutrition), transportation, housing, and more.
• Accompany patients/clients to appointments when necessary.
• Advocate on behalf of members when engaging with healthcare professionals to ensure their needs are understood and addressed effectively.
• Utilize motivational interviewing, trauma-informed care, and harm-reduction strategies to foster positive interactions and promote well-being.
• Coordinate closely with clinical staff to establish well-structured discharge plans, ensuring a smooth transition for patients.
• Monitor and encourage treatment adherence, including medication regimens, to support optimal health outcomes.
• Provide health promotion and self-management training to empower patients in taking charge of their well-being.
• Collect and input essential data for reporting purposes, ensuring the accurate completion of project activities and monthly reports as required by funding sources.
• Engage in agency and community meetings to address patient needs and contribute to discussions related to case management concerns.
• Participate in weekly case conferences with PCPs, clinical supervisors, and peers to facilitate collaborative problem-solving for client-related challenges and ensure the delivery of high-quality case management services.
• Collect data for comprehensive initial and ongoing assessments of patient needs, including functional status, housing, mental health, substance use, and education.
• Regularly update Individual Service Plans (ISPs) during weekly client meetings and report progress at case conferences to ensure goals are met effectively.
• Provide clients with appropriate referrals for a range of services, including HIV care, housing, food, transportation, benefits counseling, mental health services, and medical support.
• Verify clients' eligibility for public assistance programs and guide them through the necessary steps to access programs such as HWLA, Medi-Cal, SSI, GR, and housing options.
• Maintain confidentiality regarding client and employee information.
• Participate in designated staff meetings, quality improvement initiatives, case conferences, and in-service trainings.
• Adhere to all organizational safety policies, procedures, and regulatory requirements to ensure a safe environment for patients, staff, and visitors.
• Participate in required safety and compliance trainings and apply learned practices in daily work activities.
• Identify, report, and help mitigate unsafe conditions, incidents, or hazards in the workplace.
• Use equipment, tools, and supplies safely and responsibly in accordance with organizational and regulatory standards.
• Maintain awareness of infection control, occupational health, and emergency preparedness procedures appropriate to the role.
• Participate in JWCH’s customer service training called AIDET on an annual basis.
• Demonstrate an understanding of AIDET (Acknowledge, Introduce, Duration, Explanation, and Thank You) to apply in patient encounters or team discussions.
• Utilize the AIDET communication framework to communicate with patients and team members in a manner that reduces patient anxiety, increases patient compliance, and improves clinical outcomes.
• Perform other duties as assigned.

Requirements

• Medical Assistant certification preferred, with at least one year of case management experience.
• High school diploma or GED required.
• Minimum of two years of experience as a care coordinator, community health worker, or in a similar role.
• Experience working with individuals with multiple chronic conditions, frequent ER visits or inpatient admissions, or those experiencing homelessness.
• Proficiency in electronic health records (EHR) and data entry required.
• Strong computer skills, including proficiency in Microsoft Word, Excel, and PowerPoint.
• Excellent verbal and written communication skills.
• Strong active listening and effective communication abilities.
• Demonstrated empathy and compassion when working with clients facing challenging life circumstances.
• Cultural competence and sensitivity to diverse social, economic, and cultural backgrounds.
• Bilingual (English/Spanish) preferred.

All JWCH, Wesley Health Centers workforce members are recommended to be fully vaccinated against COVID-19.

Employee Benefits:

At JWCH Institute, Inc., we believe in taking care of those who take care of others. If you work 30+ hours per week, you’ll enjoy competitive pay and a robust benefits package that includes:

• Medical, Dental, Vision
• Monthly employer-sponsored allowance for assistance with health premiums.
• Funded Health Savings Account (up to deductible) to assist with carrier-approved medical expenses.
• Paid time off (vacation, sick leave) and 13 paid holidays.
• 401(k) Safe Harbor Profit Sharing plan.
• Mileage reimbursement.
• Short- and long-term disability plans (LTD/STD).
• Life insurance policy & AD&D, and more!

Become part of a team where your work matters. Apply today and help us change lives, one patient at a time.

JWCH Institute, Inc + Wesley Health Centers is an Equal Opportunity and Fair Chance Employer.