Job Description

Job Summary

The

Health Home Case Manager

plays a key role in providing

comprehensive care coordination

to individuals with chronic health conditions and complex social needs. This position focuses on improving participants' overall health outcomes by promoting

stability, self-management, and access to care

. The Case Manager provides

intensive outreach, engagement, and service coordination

to ensure clients receive the support they need across medical, behavioral health, and social domains.

Case Managers work collaboratively with clients, caregivers, and community partners to develop and implement individualized

Health Action Plans (HAPs)

that address physical health, behavioral health, and social determinants of health.

Essential Duties & Responsibilities Outreach and Engagement

Conduct outreach and establish trusting relationships with clients referred to the Health Home Program. Explain program services, obtain consent and ROI forms, and complete enrollment and assessment processes. Use motivational interviewing and trauma-informed approaches to engage clients who may be resistant or ambivalent toward services.

Comprehensive Care Management

Conduct initial and ongoing assessments (PAM, PHQ-9, KATZ ADL, BMI, etc.) to identify client needs and strengths. Develop and regularly update a

Health Action Plan (HAP)

with specific short- and long-term goals. Coordinate services across medical, behavioral, and social support systems to ensure a

person-centered approach

to care. Collaborate with primary care providers, specialists, hospitals, and behavioral health agencies to support continuity of care and prevent avoidable hospitalizations.

Maintain and track caseloads

to ensure all assigned clients receive monthly follow-ups and that contact frequency aligns with Health Home requirements.

Monitor and update client status

(active, inactive, discharged, or pending) to maintain accurate and current caseload lists. Ensure that

monthly follow-ups are scheduled, completed, and documented

in a timely and compliant manner.

Care Coordination and Advocacy

Help clients schedule and attend medical and social service appointments. Facilitate communication among healthcare providers, community organizations, and family members to improve care coordination. Advocate for clients to access necessary benefits, including Medicaid, SSI/SSDI, SNAP, housing assistance, and other community programs.

Health Promotion and Education

Educate clients on disease management, medication adherence, and preventive care. Support clients in developing self-management skills and achieving health and wellness goals. Promote healthy behaviors and connect clients to resources such as exercise, nutrition, and smoking cessation programs.

Comprehensive Transitional Care

Assist clients transitioning from hospitals, rehabilitation centers, or other facilities to the community setting. Coordinate follow-up appointments and ensure continuity of care post-discharge to reduce readmissions.

Individual and Family Support

Support family and caregivers through education, resource navigation, and advocacy. Address barriers related to culture, language, and literacy to improve engagement and outcomes.

Referrals for Community and Social Support

Link clients to housing, food, transportation, financial, and educational resources. Collaborate with local community organizations and agencies to address social determinants of health.

Documentation and Compliance

Maintain accurate, timely, and compliant documentation of all encounters and interventions. Ensure all required forms (ROI, consents, HAP updates, assessments) are completed and uploaded per program standards. Submit progress notes within

24 hours

of each client encounter. Track client engagement and caseload progress through established data systems or workbooks. Meet data quality, productivity, and performance benchmarks set by DSHS and the Managed Care Organizations (MCOs).

Qualifications

Education:

Bachelor's degree in Social Work, Psychology, Nursing, Public Health, or a related field preferred or experience.

Experience:

Minimum of

two years

of experience providing case management or care coordination in healthcare, behavioral health, or social services. Experience working with Medicaid populations or individuals with chronic conditions preferred.

Skills:

Strong organizational, communication, and documentation skills. Knowledge of community resources, healthcare systems, and social service networks. Ability to work independently and as part of a multidisciplinary team. Proficiency in Microsoft Office Suite and Excel tracking systems.

Other Requirements:

Must have reliable transportation for community visits. Must pass background check and maintain HIPAA confidentiality.

Core Competencies

Trauma-Informed & Culturally Competent Practice

Motivational Interviewing and Client-Centered Communication

Crisis De-escalation and Problem-Solving Skills

Commitment to Equity and Inclusion

Accountability and Time Management

Physical and Environmental Requirements

Regularly travels to client homes, clinics, and community settings. Requires sitting, standing, and occasional lifting of up to 25 lbs. Hybrid work arrangement (field visits, remote documentation, and team meetings).

Compensation & Benefits

Competitive hourly wage/salary (DOE). Mileage reimbursement for community visits. Flexible schedule and supportive team environment. Ongoing professional development and training opportunities.

Key Benefits

Vacation:

2 weeks per year (accessible after 6 months).

Sick Leave:

24 days per year (accessible after 90 days).

Mental Health Leave:

12 days per year (accessible after 90 days).

Holidays:

12 paid holidays per year.
Job Types: Full-time, Part-time

Pay: $26.00 - $30.00 per hour

Expected hours: 40 per week

Ability to Commute:

Renton, WA 98057 (Required)
Ability to Relocate:

Renton, WA 98057: Relocate before starting work (Required)
Work Location: In person