Care Manager, Non-Medical Drivers of Health, Food Market

About The Role

DescriptionKey Responsibilities:

Deliver relevant case management and resource navigation services for high-risk children and/or pregnant women referred to WFM's patient-choice food rx program

Assists in providing a clean, safe, efficient and welcoming environment in Waco Family Medicine’s food pantry and its facility

Assists with the receiving of food items, stocking of food items, and organization of the pantry space as needed.

Conduct required patient/neighbor intake and data entry

Collaborate with internal teams on continuous improvement efforts for the patient-choice food rx program and CPW service line

Assist with the provision of Nutrition Education training to patient/neighbors

Assess and respond to psychosocial, financial, NMDOH, functional, cognitive and medical needs.

Identify and address gaps in patient care through visits to the Food Market; Identify and utilize patient’s systems of support and facilitators for reaching health goals.

Conduct comprehensive psychosocial needs assessments, screen and refer to appropriate agencies or internal programs for NMDOH needs.

Develop individualized care plans for eligible care management patients focusing on short and long-term medical, behavioral health, and NMDOH goals of care.

Assist patients in navigating the healthcare system and Waco Family Medicine’s food pantry.

Apply knowledge of community resources to address care gaps or improve quality of life conditions.

Full-time, 40 hours per week with a work schedule of Monday – Thursday with evening hours, and scheduled Saturdays.

OTHER DUTIES

As assigned by supervisors.

Qualifications Care Manager, Non-Medical Drivers of Health, Food Market

REPORTS TO: Director of Non-Medical Drivers of Health Programs & Program Manager for Non Medical Drivers of Health Programs

EDUCATION & EXPRIENCE: Master's Degree in Social Work required; Active Texas Licensed Master Social Worker required; Experience in social services, counseling, or case management preferred; Experience providing social services in healthcare settings preferred; Fluency in English and Spanish is highly preferred to support effective engagement with Spanish-speaking patients, community members, partners, and stakeholders to advance equitable access to services.

SKILLS: Knowledge of health care conditions and needs of children and pregnant women; Knowledge of non-medical factors that influence access to care and health outcomes of children and pregnant women; Ability to learn and apply case management and patient education skills; Strong interpersonal skills with the ability to build effective relationships across interdisciplinary care teams and with patients; Proficiency in problem identification and care plan development; Professional interaction skills with medical providers and other healthcare professionals; Skillfully conduct psychosocial and non-medical drivers of health (NMDOH) assessments and screenings; Ability to learn and apply evidence-based behavioral strategies and interventions for NMDOH; Strong written and oral communication skills.

PHYSICAL AND MENTAL REQUIREMENTS

Possess a valid Texas driver’s license and appropriate liability insurance

Access to personal transportation

Visual and auditory accuracy

Shift length varies

Indoor setting

Continuous use of computer

Long periods of sitting

Frequent use of telephone and/or smart devices

Continuous repetitive grasping and manipulation of both hands

Continuous conversational communication

Occasional reaching, walking, squatting, bending, kneeling, twisting and climbing