Case Manager​/Patient Advocate

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This position connects patients to appropriate resources; assists patients with questions or concerns while navigating through the FTHC systems; and manages the coordination of care for patients who are most at risk for health deterioration, sentinel events, and/or poor outcomes and work holistically to ensure that care and treatment plans meet the physical, social, and emotional needs of patients.

• Monitor daily patients census and assignments to assure all patients are assessed for case management needs including coordination of care, follow-up treatment and care planning, consultations, referrals, advocacy and patient education.
• Connect patients to resources available throughout the Health Center and in the tribal/local community such as housing, social services, public assistance, and counseling services.
• Offers advocacy services to uninsured patients and their families to inform them of the availability and eligibility requirements of various health insurance coverage and/or programs.
• Meets and assists patients in identifying case management services, individuals’ treatment and care plans following best practices, and coordinating related referrals and services.
• Assist with coordination with referral sources, family members, community agencies, & other care and treatment providers to provide the best treatment & case management options for patients.
• Provide a system to ensure patients, particularly elders or other vulnerable patients, are supported while seeking health care services at the FTHC or to referral sources. Coordinates care between FTHC services to ensure health/social needs are met, as well as continuity of care is maintained.
• Maintain effective communication with health care team members relating to assessment and planning needs and provider orders and help assist in locating resources for homecare, durable medical equipment, transportation, skilled nursing, facility placement, and outpatient follow-up.
• Work in conjunction with health center staff and other tribal/community partners to create and reinforce a patient focused culture within the Tribe. Work cooperatively with Health Center programs and services to ensure optimal patient access and satisfaction.
• Develops service plans which outline a plan of action with patients needing case management services and makes referrals in accordance with plans to FTHC or external providers.
• Accurately completes in a timely manner all necessary forms, reports, patient case notes, case recordings and statistical reports.
• Provides information regarding Advance Directives, assists in filling out the forms, and obtaining appropriate witnesses, if necessary, to complete the documentation of Advance Directives.
• Documents complaints and concerns by listening to patient and patient family complaints; documenting details; determining what resolution is sought.
• Addresses complaints/issues by listening to patients and their families; directing them to appropriate supervisor or medical provider; helping them present facts to the health center management; developing acceptable resolutions; following-up on outcomes.
• Consults in the development of strategies to improve patient satisfaction; identifies best practice and opportunities for improvement and works collaboratively with leaders and staff; assists with staff education on improving patient satisfaction/experience opportunities.
• Complete all required and additional progress notes and uploading progress notes and accompanying documents to FTHC’s electronic health record (EHR) system in a timely manner.
• Performs other job-related duties as assigned by the supervisor.