Provide case management that includes but is not limited to assessment of patient/family needs with respect to concrete services, research of resources, advocacy on behalf of patient/family, linking patient to appropriate resources, providing follow-up as needed. Provision of services at multiple sites.
Essential Job Functions:
1. Evaluate a patient’s eligibility for entitlement programs and refer to the Member Services department or outside agency as appropriate.
2. Assess and evaluate patient/family’ needs with respect to psycho-social concrete services that may include but not limited to forms completion, researching resources, linking with appropriate services, developing care plan as appropriate, providing follow-up as needed.
3. Conduct research of resources as needed for patient/family needs. May include, but not limited to: updating information, housing, food, transportation, chronic illness support programs (initial/ongoing support), language-specific services as relative to AHS patient population.
4. Assist patients with understanding and completing forms, such as applications for Medi-Cal redetermination, Medi-Cal, SSI, SDI, department of rehabilitation, citizenship waiver, housing.
5. Provide patient education about advanced directives and assist patient/families to complete forms as appropriate.
6. Advocate for and provide referrals and follow-up for patients regarding other community services when needed.
7. Provide counseling, information referral and follow-up services for AHS patients in family violence situations.
8. Serve as a liaison with external agencies as appropriate.
9. Consult with medical providers (physicians, physician assistants, and nurses) at AHS or external agencies regarding patient cases.
10. Track patients who are lost to care and have mental health issues.
11. Maintain patient records and document services provided via encounter forms and logs.
12. Maintain/Update mental health database.
13. Participate in behavioral health services meetings and Domestic Violence Committee.
1. Provide follow-up with patients who cancel or do not show up for their appointments with a behavioral health staff.
2. Conduct phone call follow-up for patients prescribed medication for their mental illness
3. Conduct screening for conditions such as depression and dementia.
4. Conduct assessment on patient’s activities of daily living.
5. Interrelationships with Other Staff like Clinic Administrative staff (i.e. Medical Director, Associate Med. Director, etc.), Clinic medical providers, Clinic Support Services staff, Member Services staff, Nursing Staff, Health Education Department Staff
1. Serve as liaison with Asian Community Mental Health Services, Asian Pacific Psychological Services, or other psychiatric/counseling institutions to coordinate patient care for AHS patients.
2. Update and maintain referral resources and strengthen linkages with other agencies and community organizations to provide a full spectrum of referral services to AHS patients.
3. Serve as a liaison with external agencies as appropriate.
4. Advocate for AHS patients and their families to assure availability and utilization of appropriate community services.
Education: High School Diploma
Experience: Four years of relevant work experience
Preferred: Familiarity with and commitment to serving the Asian community, strong background in Media-Cal and other entitlement programs, Biliterate in Chinese; willingness to learn, Self state, takes initiative with projects, Yes, to communicate with patients who are mostly monolingual. Use of Cantonese or Toisanese. 90% of the time.
Bilingual, and bicultural in Cantonese language
Last updated 10/12/2019