Bilingual Case Manager - PT (20 hours/week)
Clinica Family Health Services - Boulder, CO

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This job exists to: Provide self management through education, goal setting and follow up to patients .

ESSENTIAL DUTIES AND RESPONSIBILITIES:
  • Manage Planned Care on the Pod as per Registry Workflows and respond to support needs on the pod during the day.
o Prenatal, including tracking of all OB outcomes and delivery information

o Newborn visits

o Weight loss counseling

o Basic nutrition counseling

o Well Child Checks (1 year always & when provider requests)

o Diabetes

o Hypertension/Cholesterol

o Tobacco Cessation

o Chronic disease self management and goal setting with all Planned Care patients

o Discussing a1c and lipid results w/Pts over the phone and set goals with patients to improve these numbers

  • Facilitation of patient Group Visits
o Group visit advertising, marketing, creation and trouble shooting

o Patient recruitment and scheduling, in collaboration with clinic staff

o Preparation of group materials for education and activities

o Set up/tear down of GV space

o Facilitation of patient-group discussions

o Provide Health education as needed based on group needs/type

o Anticipatory Guidance as defined by protocol

o Basic diagnosis-specific education for Planned Care diagnoses

  • Prenatal Plus program
o Identify all OB patients on Medicaid and screen for eligibility

o Complete comprehensive intake on all eligible patients

o Provide continuity care throughout pregnancy in collaboration with BHP, RD, and PCP

o All PN+ patients should see CM or BHP at each visit as appropriate

o Confirm all data has been entered correctly and completely in the EMR

o Submit completed shadow chart to supervisor for billing log

  • Brief behavioral health interventions (lower-acuity patients)
o As requested by PCP; use these opportunities to refer to higher-level resources as appropriate

o Goal setting and education

o Depression (PHQ score within scope) in conjunction with the Behavioral Health Professional

o Stress management and relaxation techniques

o Support Behavioral Health Professional, PCP or RN in crisis intervention:

§ Domestic violence

§ Child abuse & neglect

§ Suicidal ideation

o Teen confidentiality

o Pregnancy decision counseling

o Facilitate transfer of higher-acuity patients to BHP

o Referrals to community resources as per Resource Cards

  • Demonstrate knowledge of the principles of growth and development over the life span.
  • Accountable Care Program:
o In conjunction with the ACO Home Visit Provider, conduct home visits with designated Clinica ACO patients in the Boulder/Adams county areas to provide coordination of care for patients after discharge and facilitate handoff to primary care team

o Document home visit in EMR according to protocol

o Manage HARMS 8 task box to conduct and document HARMS 8 Risk Assessments with designated ACO patients according to protocol

o Manage a list of “Never Before Seen” patients who have been assigned to CFHS per ACO but have not yet been seen at CFHS – offering CFHS services, create patient chart, schedule appointments and document per protocol
A. Education / Experience

1. BA degree in Human Services field or equivalent experience.

2. Experience providing health education is preferred.

B. Knowledge, skills and abilities:
1. Excellent verbal and written communication skills in English and Spanish required.

2. Ability to flourish in a team management system.

3. Sensitivity to low income, ethnic minority community.

4. Excellent organizational skills.

5. Excellence attendance.

6. Ability to flourish in an unpredictable daily flow.

7. Ability to/interest in providing health education and support in an individual and group setting