Case Manager

Job description

Essential Functions: - Conducts psychosocial assessments and social determinant of health screenings and responds to referrals from providers and other Spectrum staff - Provides comprehensive patient education on and resource referrals for identified social determinant of health and other psychosocial needs including financial/food/housing/transportation insecurity, interpersonal violence, immigration concerns, and educational needs - Assists patients in understanding their diagnoses, treatment options, and resources available to them. Provides support for advanced care planning - Troubleshoots barriers to adhering to plan of care - Meets with patients in office to identify patient needs/concerns and making warm/lukewarm handoffs to internal and external resources - Assist with form completion and applications for benefits and services - Conducts phone outreach and follow-up to referred/identified patients - Conducts transitions of care outreach to patients recently discharged from the ED or hospital - Provides longitudinal follow-up support to target patients and populations per the needs of the care management program - Assists with referrals to skilled home care services and hom...