Integrated Care Case Manager

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

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