Position purpose: The Care Manager is responsible for coordinating screening and providing the intervention of patients with identified complex chronic care needs. Acts as a connector between patient needs and the resources provided by the care management program. Provides guidance and leadership in the care management program to those in the healthcare organization as well as ensuring the patients receive the best possible care.
Corporate Philosophy: It is the obligation of each employee of Esperanza Health Centers to abide by and promote the missions and values of the Health Center to ensure that excellent services are delivered with compassion.
To promote healthy lifestyles and improve our patients’ health through the provision of high quality health care and wellness services in the communities of Chicago’s southwest side.
eliminating barriers that restrict access to quality health care.
impacting the community by providing quality integrated primary care and behavioral health services.
building our communities by helping families with prevention and self-care education.
Primary Duties and Responsibilities: (The following duties and responsibilities are all essential job functions except for those that begin with the word “May.”)
1. Identifies, tracks and manages care for the highest risk patients
2. Conducts initial care coordination screening eligibility and performs comprehensive risk assessment
3. Oversees in the development and implementation of an integrated patient care plan for each of the highest risk patients.
4. Ongoing clinical assessment, monitoring and follow up for the high risk patients
5. Utilize standing orders and clinical orders for chronic disease management within scope of clinical practice
6. Assesses psychological needs and ability to benefit from community resources and referrals to outside agencies/programs when appropriate
7. Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.
8. Performs medication review, reconciliation and coordination with a licensed professional for medication adjustment
9. Participates in the evaluation of the care management programs
10. Collaborates and participates in the selection, development and maintenance of patient education materials related to healthy lifestyle changes and specific disease management topics.
11. Makes home visits, as needed, to perform comprehensive HRA to determine level of care coordination needs
12. Assists in the maintenance of the patients’ health, wellness and prevention of secondary disease complications by providing education, counseling and support
13. Handles protective health information in a manner consistent with the Health Insurance Portability and Accountability Act (HIPPA)
14. To live up to Esperanza’s mission of being truly involved in the community all staff members are expected to participate in outreach activities between 3 to 5 times per year; including but not limited to the Annual Fundraiser, Community Garden(s), and Health Fairs.
15. Other duties as assigned
General Job Requirements:
1. Social Worker (MSW) or related title in a similar discipline
2. 2-3 years of experience in disease management or care management
3. Ability to speak, read and comprehend English and Spanish
4. Displays strong time management and organizational skills in a high intensity work environment.
5. Desire to be a self-starter; take initiative.
6. Flexibility to work evenings and/or weekends, if necessary.
7. Demonstrates problem solving, decision making, and sound judgment as well as customer service skills.
8. Proficient in Electronic Health Record, Microsoft Word and Excel
9. Exceptional organizational and interpersonal skills, with attention to detail required; strong oral/written communication skills is a must
EDUCATION: MSW and LSW or LCSW
PREFERRED EXPERIENCE: 3-5 years
About Esperanza Health Centers
Esperanza Health Centers serves an area that is in great need of quality healthcare. Families in Esperanza's service area experience significant economic, educational, and health disparities. More than 53 percent of residents live below twice the poverty level. Large portions of Esperanza's service area have been designated as a Medically Underserved Area and a Health Professional Shortage Area by the Health Resources and Services Administration.
All of our full-time providers and all of our clinical staff are bilingual and bicultural. Our services and programs are carefully tailored to the needs and culture of the communities we serve.
Esperanza Health Centers is a Health Center Program grantee under 42 U.S.C. 254b, and a deemed Public Health Service employee under 42 U.S.C. 233(g)-(n).
To promote healthy lifestyles & improve our patients’ health through the provision of high quality health care and wellness services in the communities of Chicago’s southwest side.
Esperanza means hope in Spanish. In living up to its name, Esperanza Health Centers envisions healthy communities where resources are woven together, allowing community residents to realize their... full potential through optimum health regardless of immigration status, race/ethnicity, income or ability to obtain insurance.
HOPE: eliminating barriers that restrict access to quality health care.
HEALTH: impacting the community by providing quality integrated primary care and behavioral health services.
FAMILY: building our communities by helping families with prevention and self-care education.