Overview Join to apply for the Case Manager – Bridge role at Central Health . Central Health’s Medical Bridge is an innovative program that fills gaps in care for vulnerable individuals, especially those experiencing homelessness. We see patients at our Capital Plaza location as well as various mobile sites. The Case Manager acts as a critical member of the team who provides intensive case management for patients seen through the Bridge Program. The Bridge Case Manager is a member of the multidisciplinary bridge team, providing intensive case management for patients who are seen in the program, supporting patients until we are able to connect them to a medical home. This support includes welcoming new patients, screening for non-medical drivers of health needs, engaging with them as needed, and coordinating their social needs as well as linkages to medical and behavioral services. The case manager is skilled in crisis management and provides timely referrals to appropriate substance abuse, physical health and mental health treatment, as well as support in accessing benefits and entitlements, and support in identifying appropriate and affordable housing as part of a comprehensive approach to ending homelessness and achieving self-sufficiency.
Responsibilities Develops individualized treatment plans and psychosocial goals for short- and long-term care plans by assessing individual needs, strengths, barriers and readiness to change
Provides crisis intervention services (assessment, evaluation of risk, referral and follow up)
Effectively de-escalates heightened situations with patients experiencing trauma, exacerbated mental health symptoms, and behavioral complexity
Provides goal oriented and short-term services (engagement, case management, counseling linkage) with complex psychosocial needs
Educates patients on available community resources
Teaches patients through structure and modeling appropriate expectations and guides them on following through with their tasks
Helps patients identify and manage challenges or barriers in navigating health and government benefits
Accompanies patients to appointments as needed
Assists patients directly or indirectly with housing survey (Coordinated Assessment)
Works with patients on discharge planning by reviewing potential transitional housing programs, assisting with room rental search and applications for housing units
Collaborates with housing specialists and/or other resources to identify and address psychological, social and medical needs, and coordinates referrals for housing programs
Works collaboratively with treatment team, community resources and partner agencies involved in patient care and participates in weekly case conference with multidisciplinary bridge team to discuss patient care plan
Assists Bridge team as needed in coordinating transportation for appointments, picking up medications and other support services
Other duties as assigned
Knowledge, Skills and Abilities High level of skill at building relationships and providing excellent customer service
High level of problem-solving skills to better serve patients and staff
Strong attention to detail and accuracy
Excellent verbal and written communication skills
Demonstrated knowledge of community resources available and how to access resources for the benefit of clients
Demonstrated success in collaborating with multidisciplinary team members
Bilingual (Spanish/English) preferred
Required Education Bachelor's degree in Social Work or related field (higher degree accepted)
Required Experience Internship or work in field related to social work, case management, or counseling individuals in crisis/trauma situations
Demonstrated knowledge of community resources available and how to access resources for the benefit of clients
Referrals increase your chances of interviewing at Central Health by 2x