Erie Family Health Centers

Patient Navigator

• Enroll patients in IBCCP
• Track bills, budget, and caseload; enter information into Cornerstone
• Provide case management to IBCCP enrollees diagnosed with cancer
• Work with an RN to ensure oversight
• Provide patient navigation for high-risk and newly diagnosed cancer patients, primarily breast cancer and potentially colorectal and cervical cancer patients
• Help patients understand diagnoses, treatment options, and internal and external resources
• Maintain current knowledge of community resources
• Coordinate support groups and events, including two monthly breast cancer support groups, two yearly mobile salons, and one yearly cervical and breast cancer event
• Perform other duties as assigned

Manager

• Provide 1-on-1 supervision, leadership, coaching, and support to direct reports
• Complete new HIV intakes, manage the HIV pool in the EMR system, and assign cases/patients to team members
• Manage staff schedules, time-off requests, staffing coverage, hiring, onboarding, and training
• Monitor team workflows, performance metrics, and daily activities
• Conduct quality assurance of case management documentation and provide feedback to direct reports
• Communicate initiatives, workflows, and program changes and provide updates to the LHL Program Manager
• Manage a reduced caseload of higher-need, high-complexity HIV-positive clients
• Coordinate medical treatments, treatment adherence counseling, benefits enrollment, resource referrals, and Emergency Financial Assistance
• Refer and link clients to services, monitor follow-through, and assess medical acuity, including home and hospital visits as necessary
• Collaborate with HIV Team members, medical providers, and community agencies
• Attend team meetings, case conferences, outreach activities, and support groups
• Document client care communication in the electronic medical record and state database
• Participate in quality improvement projects and program initiatives
• Assist with LHL events, attend required trainings and meetings, and perform other assigned duties

Medical Case Manager Team Leader

Consultant

• Provide PCP-initiated behavioral health consultation services, including differential diagnosis, screenings, psychoeducation, brief intervention, and referrals
• Maintain a caseload and provide individualized mental health assessments, treatment, and counseling
• Conduct individual, couples, and/or family consultations
• Perform functional and strength-based assessment and diagnosis
• Provide psychoeducation, medication adherence counseling, and disease self-management counseling
• Use Motivational Interviewing and brief problem-solving cognitive interventions
• Develop self-care plans and provide skills training for disease self-management, coping, distress tolerance, stress reduction, and relaxation
• Evaluate substance use/abuse and develop harm reduction strategies
• Consult with PCPs on treatment planning and monitoring biopsychosocial treatment plans
• Coordinate patient care with primary care staff
• Complete psychiatric intake evaluations and appropriate screenings
• Identify, refer, and advocate for patients needing specialty behavioral health and other services
• Provide crisis intervention and be immediately available during working hours for psychiatric emergencies
• Participate in health center emergency response
• Participate in individual supervision and monthly clinical group supervision
• Supervise first- and second-year interns as needed and when available
• Complete EMR charting within 48 hours, including assessments, progress notes, and billing

Patient Navigator

Medical Case Manager Team Leader

Behavioral Health Consultant