Job Summary

JOB SUMMARY: The Case Manager, Community Health at the City of Frederick’s Federally Qualified Health Center (FQHC) will provide comprehensive case management and case coordination services to patients, particularly those facing barriers to accessing healthcare. The Case Manager will work closely with healthcare providers, other Housing and Human Services Case Managers, and community organizations to ensure that patients—especially those with chronic health conditions or complex care needs—receive the medical care, social services, and support they need to achieve optimal health outcomes. This role will focus on addressing social determinants of health such as housing instability, food insecurity, transportation challenges, and access to medications or healthcare.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Conducts intake assessments for new patients to evaluate their physical, behavioral, and social needs, including health conditions, living situation, access to food and transportation, and financial resources.
• Develops and implements individualized care plans in collaboration with healthcare providers, ensuring patients receive appropriate services related to medical care, mental health, and social services.
• Coordinates patient care by facilitating referrals to specialists, mental health providers, substance abuse services, and other necessary healthcare services.
• Helps patients navigate the healthcare system, including assistance with scheduling appointments, understanding medical instructions, and connecting to resources like Medicaid or other insurance programs.
• Educates patients about their conditions, treatment options, and self-management strategies, ensuring they understand how to effectively manage their health.
• Identifies and addresses social determinants of health affecting patients, including housing instability, food insecurity, transportation barriers, and lack of access to healthcare services.
• Connects patients with other HHS programs and local community resources such as food pantries, housing assistance programs, transportation services, and financial assistance programs.
• Provides regular follow-up and check-ins with patients to track their progress, ensure compliance with treatment plans, and addresses any new barriers to care.
• Assists patients with navigating the complexities of public health insurance (e.g., Medicaid) and community-based health programs.
• Maintains accurate, confidential case records for all patients in accordance with FQHC policies and HIPAA regulations.
• Documents all patient interactions, progress notes and follow-up activities in the electronic health record (HER) system.
• Reports on patient outcomes and case management activities to supervisors and funding agencies, as required.
• Performs other duties as assigned.

QUALIFICATIONS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

REQUIRED EDUCATION AND/OR EXPERIENCE:

• Any combination of training and experience which demonstrates ability to perform the duties and responsibilities as described; a typical qualifying background would include coursework in social work, nursing, public health, health education, or a related field.
• Two (2) years of experience in healthcare case management, community health, or social services, preferably in an FQHC or clinic setting.
• Experience with underserved populations and familiarity with social determinants of health is highly desirable.

REQUIRED CERTIFICATES AND/OR LICENSES:

Vehicle Operator’s license with satisfactory driving record that meets insurability standards of the City’s insurance carrier is required. The employee must maintain the license for the duration of their employment.

REQUIRED SKILLS:

• Must be fluent in both English and Spanish, including the ability to speak, read, and write in both languages.
• Strong interpersonal communication skills and an ability to provide services to persons who are low-income and/or homeless.
• Good written and oral communication skills.
• Proficiency in computer programs such as Microsoft Office (Word, Outlook, Excel, PowerPoint, and Access).

OTHER DESIRABLES:

Ability to communicate using American Sign Language.

PHYSICAL DEMANDS:

The physical demands described here are representative of those that must be met by the incumbent to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this position, the employee is frequently required to remain in a stationary position and/or to move about for long periods of time, and position self to reach items above or below their reach. The employee must occasionally ascend and descend levels and/or ladders. The employee is occasionally required to lift and/or move up to 20 lbs. Specific vision abilities required by this job include the ability to observe and inspect items directly in front or to either side of self, to assess items at a distance, to distinguish colors, depth perception, and ability to adjust focus. The employee is subject to the use of Universal Precautions as required by the Bloodborne Pathogens Exposure Control Plan, and to annual Tuberculosis (TB) Testing as required by the Tuberculosis Prevention Plan.

WORK ENVIRONMENT/CONDITION:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee will primarily perform their duties in an indoor setting, however, in exposed periodically to outside weather conditions. The employee regularly encounters clients who are intoxicated, under the influence of unknown substances, may be affected by communicable diseases, and/or appear affected by serious mental health problems. Open-toed shoes and sandals are prohibited in the work setting; steel-toed boots and other personal protective equipment use may be required.