Case Manager, Medical

SACRAMENTO NATIVE AMERICAN HEALTH CENTER INC; Sacramento (CA); On-site; USD 34,000 - 37,000; Full time

Job summary

Sacramento Native American Health Center Inc. seeks a Medical Case Manager to deliver comprehensive care coordination for patients with complex physical, behavioral, dental, and social needs.

You will manage referrals, assist with DME, and maintain accurate documentation, while engaging patients through direct outreach and team-based care. The role emphasizes collaboration with clinical and community partners, adherence to HIPAA and regulatory standards, and flexible site coverage to support

Qualifications

• Two or more years of experience in health, social services, or related field.
• Experience with Electronic Health Records (EHR) environments.
• Knowledge of culture, health disparities, and issues significant to homeless individuals and low-income families.

Responsibilities

• Coordinate referrals to appropriate programs based on patient needs and eligibility.
• Assist with durable medical equipment (DME) referrals for the medical department.
• Ensure productivity goals are met weekly.
• Assess health status and develop individualized care plans with short- and long-term goals.
• Maintain ongoing engagement with patients through in-person meetings and outreach.
• Provide in-person support in waiting rooms and during appointments.
• Document patient interactions, care plans, and outcomes accurately in records.
• Collaborate with dental and behavioral health teams for care coordination.

Skills

Excellent computer skills

Excellent communication skills

Organizational skills

Confidentiality

Teamwork

Independent work

Cross-sector collaboration

Education

Bachelor’s degree or equivalent

Tools

NextGen EHR

i2i Population Health Management System

Job description

Here at SNAHC, you are joining a team and company at a time of growth and transformation. You will love being surrounded by people who are as passionate as you are about healthcare and giving back to the community. Please note that individual total compensation for this position will be determined at the Company's sole discretion and the wage range for this role considers a wide range of factors including but not limited to skill sets; experience and training; licensure and certifications; and other business and organizational needs. At SNAHC, it is not typical for an individual to be hired at or near the top of the range for their role and compensation decisions are dependent on the facts and circumstances of each case. A reasonable estimate of the current range is $25.00/HR-$27.00/HR.*Role may need to float to other SNAHC locationsPosition Summary:The Medical Case Manager (CMC) provides comprehensive case management and care coordination for patients with complex physical, behavioral, dental, and social needs. While primarily managing an assigned panel, the support provided extends to all patients as necessary. The CMC is responsible for referrals, client interviews, data collection, confidential record-keeping, client recruitment, and assisting with establishing care at SNAHC. This role involves close collaboration with program stakeholders, healthcare providers, healthcare payors, social services agencies, and other community-based organizations to ensure seamless coordination of services and patient support.Essential Functions:Coordinate referrals to appropriate programs based on eligibility criteria, patient needs, and provider assignment.Assists with durable medical equipment (DME) referrals for the medical department.Ensures productivity goals are met weekly.Assesses patients’ health status, regional resource utilization, and barriers to care to develop individualized care plans with short- and long-term goals.Maintains ongoing and effective engagement with assigned patients through in-person meetings, text/telephone communication, and community outreach.Provides in-person support to patients in waiting rooms and during appointmentsEnsure all patients have accurate and up-to-date shared care plans.Connects clients to a variety of services and resources to address their comprehensive needs.Participate in medical team huddles to enhance communication between the care team, partner outreach, and housing agencies.Maintains clear and timely documentation of all patient interactions, care plans, and outcomes in accordance with program requirements.Participates in care coordination meetings with dental and behavioral health departments for internal case conferences.Track patient panels in the electronic Population Health Management System (i.e., i2i).Collaborate with patients to follow organizational guidelines through non-judgmental and caring interactions.Support quality improvement initiatives in accordance with the organization's mission and strategic goals, federal and state laws and regulations, and accreditation standards.Comply with all state and federal laws and regulations, including HIPAA, sexual harassment, scope of practice, OSHA, etc.May be required to travel between sites for coverage and/or meetings.Other duties as assigned.Skills and Abilities:Excellent computer skills, preferably with Windows, including Microsoft Office SuiteExcellent telephone and communication skillsMust possess excellent organizational, writing, and verbal skills.Ability to work independently, set priorities, and work well under pressure.Ability to maintain a high degree of confidentialityAbility to demonstrate superior professionalism when dealing with patients, subordinates, colleagues,community members and vendors.Ability to collaborate and convene across sectors and organizational levels.Competencies:Communication and RelationshipsInitiativePlanning and OrganizingSafetyTeamworkProgram Specific WorkflowsMinimum Qualifications:Two years or more in a Health, Social Services, or related fieldExperience working in an Electronic Health Record (EHR) environment.Experience and knowledge of the culture and environmental issues significant to homeless individuals, low-income families, mental health patients, and individuals involved in the criminal justice system.Experience with interventions such as motivational interviewing, de-escalation, harm reduction, and trauma-informed care in a diverse clinical setting.Preferred Qualifications:Bachelor’s Degree or equivalent work experience in a Health, Social Services, or related field.Knowledge, understanding, and use of Electronic Health/Administrative Records, Resource Patient Management Systems NextGen.Experience in an FQHC settingKnowledge of and experience with Social Determinants of HealthKnowledge of traditional, cultural, and spiritual practices of the diverse AI/AN community, as well as the ability to work with other racially, culturally, ethnically, and financially diverse populations.BilingualPlease Note: This position may be grant funded. Continued employment is contingent upon renewed or additional funding and may be discontinued at the close of the grant cycle. Grant funding for any position does not impart any contractual right, either expressed or implied, to remain in Sacramento Native American Health Center, Inc.’s employment for a specific period of time. Grant funding does not affect the Sacramento Native American Health Center, Inc.’s status as an “at will” employer.