Experience and Skills:
Areas of Responsibility:
- Works with Case Management teams at COTS and PHC to effectively
fulfill guidelines set forth by the HCH grant for homeless
individuals in Petaluma during their Care Transitions phase of their
- Reviews daily referrals, meets with clients admitted to hospital
care in order to obtain program consent and review client’s
discharge plan, medical follow up, and psychosocial needs.
- Assists client in establishing individualized health goals,
identifying potential problems/barriers: provides health education
resources. Provides advocacy for client and monitor client’s
progress. Coordinates logistics for health goal adherence.
- Assists in timely scheduling of primary care and other medical
appointments to support client health. May attend appointments with client.
- Links individuals to application assistance for health coverage
programs. Performs client benefit enrollment in areas where certified/approved.
- Maintains good working relationship with community health partners
by working as a liaison with other agencies and the community:
participates in the Task Force for the Homeless case manager
- Documents all clinical support tasks to meet grant requirements
which may include data entry.
- Participates in quality activities to monitor and improve client
service quality such as Case Reviews.
- Assists in locating clients in support of outreach function.
- Participates in ongoing training and review.
- Other duties as assigned.
- High school diploma or GED required.
- Driver’s license w clean driving record and auto insurance.
- Minimum one year community health experience with various program
involvement, CHW, MA or CNA certificate or 5 years community
- Experience working with homeless, alcohol, or drug addicted and
special needs populations.
- Familiarity with social service resources in Sonoma County.
- Bilingual Spanish and English (speak, read, write) required
- Experience working in a healthcare setting preferred.
- Project coordination experience preferred.
- Prior case management experience preferred.
Licenses and Certifications:
CHW, MA or CNA certificate preferred
Bilingual in English and Spanish, both written and verbal preferred.
Ability to add, subtract, multiply, and divide all units of measure,
using whole numbers, common fractions, and decimals.
Ability to recognize problems, collect data, and establish facts.
Microsoft Office, Outlook, Word, and Excel.
Use of a web browser.
Electronic Medical Records.
The physical demands described here are representative of those that
must be met by an employee 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 job, the employee is frequently
required to sit ergonomically correctly; use hands to finger, handle
or feel, ability to talk and/or hear. The employee is required to
stand; walk: reach with hands and arms: climb or balance and stoop,
kneel, crouch or crawl. The employee must frequently lift and/or move
up to 15 pounds and occasionally lift and/or move up to 15 pounds.
Specific vision abilities required by this job include close vision,
distance vision, color vision, peripheral vision, depth perception and
the ability to focus. Repetitive motion with word processing and data
entry. Heavy phone use.
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. General outpatient clinic environment; however the work
environments vary among the various clinics. The noise level in the
work environment is usually moderate.