Older Adult Services Case Manager

Case Manager for Older Adults (ISS Program) assists low-income older adults (60 and older) residing in Morris County and their families in accessing appropriate clinical and social services, including appropriate health screenings, diagnostic testing, primary medical, oral, and behavioral health care, support services and treatment, to achieve improved health outcomes. The Case Manager focuses on needs and barriers (such as financial, cultural, language, insurance) that prevent patients from achieving health outcomes. The Case Manager plays an integral role in the care coordination and management of patients and is a key member of the Care Team. Travel is expected throughout Morris County to meet with patients and attend some community meetings. The Case Manager reports to the Coordinator of Older Adult Services and is a part of the behavioral health department.

Essential Functions, Duties, and Responsibilities

• Works as part of the Care Team to identify patients in need of services and communicates with the patient’s healthcare team of progress of case and of unidentified needs.
• Provides in-reach to Zufall Health Center staff to encourage referrals.
• Provides outreach to community organizations to encourage referrals.  
• Conducts intake process and determines clinical and social needs and coordinates plan of care for each patient. 
• Provides ongoing, intensive case management to all program participants based on their identified areas of need. 
• Maintains regular contact with program participants including phone/video communication at least once a month, in-community visits every three months, and home visits every six months. 
• Schedules and coordinates appointments and follows up on missed appointments, rescheduling as needed. Contacts patients who are overdue for return visits. Monitors patient participation in follow-up care.
• Assists patients with arrangements for transportation, interpretation and translation, and other barriers to attending appointments and accessing care. In the older adult population, barriers may include but are not limited to dementia, mobility issues, low motivation related to depression, and inadequate social support systems.
• Assists patients with completion of medical and prescription forms and request to other providers and agencies. 
• Engages caregiver(s)/family with the plan of care with permission of patient whenever available or appropriate.
• Enters interventions done and plans in electronic health record via telephone encounter or case management notes. Scans documents related to patient care into their electronic health record. 
• Assists medical providers with contacting patients to discuss results and additional procedures or recommendations for other services such as clinical pharmacy services.
• Educates patients about what, why and how tests are being done. Instructs patients with preparation for all procedures
• Facilitates patient enrollment into appropriate providers, programs, services, or organizations as needed. 
• Assists patients with applications for Charity Care at local hospitals, Medicaid, NJ Family Care and other financial support benefits or insurances as appropriate.
• Increase patients’ sense of empowerment in their ability to navigate the healthcare system. Provide support, empathy, and guidance to patients related to their healthcare journey. 
• Acts as advocate for patients with community organizations and governmental agencies.
• Establishes and cultivates excellent external referral relationships with community-based organizations who are referring or who will be referred to, as appropriate. Develops and maintains a referral resource list specific to the older adult population. 
• Assists with tracking program enrollment, levels of services provided, collecting data, and tracking program activities and expenses. 
• Attend continuing education trainings related to older adults. 
• Coordinate with Zufall’s Outreach and Enrollment team to complete at least four outreach/community education activities annually. 
• Works to meet program target objectives. 
• Other duties as assigned.

• Excellent knowledge of the health and psychosocial issues of the older adult population 
• Excellent knowledge of available community services and resources
• Excellent communication and interpersonal skills
• Bilingual Spanish/English required
• Ability to interact well with patients, Zufall staff, and outside providers and organizations
• Demonstrate effective follow through with all tasks
• Ability to maintain high level of confidentially
• Ability to work independently and complete assignments in a timely manner
• Working knowledge of Zufall policies and procedures, and adoption of mission and values of Zufall
• Able to work in a team
• Learn and apply the trauma informed care principles within the scope of the position
• Maintains calm demeanor and empathetic, patient-centered orientation even under stressful circumstances
• Knowledge of Microsoft Office and use of electronic medical records

Education, Training and Experience

• Bachelor’s Degree in social work or related field; MSW preferred 
• Minimum of two years’ experience in clinical or social service setting
• Experience working with older adults preferred