Geriatric Case Manager

• Communicate the patient’s plan of care with providers, care managers, and external partners to ensure shared understanding of patient goals.
• Review care documentation to identify gaps or inconsistencies in treatment and collaborate with providers to address in alignment with the care plan.
• Maintain ongoing communication with the care team to align on updates, concerns, and progress toward patient goals.
• Participate in patient appointments or team meetings to remain informed on care progress and changes.
• Refer patients to appropriate community resources and outside agencies, including Social Services, to support care needs.

• Reassess the patient care plan annually or upon significant life changes.
• Record case details, demographics, services provided, and referrals in the electronic health record system.
• Address telephone encounters, actions, and referrals in the electronic health record system in accordance with Finger Lakes Community Health policies and procedures.

• Perform other related duties as assigned by the supervisor.

• Sitting/Standing: Prolonged sitting with occasional standing or walking.
• Computer Use: Frequent typing and prolonged screen time.
• Light Lifting: Frequently lifting or carrying objects up to 15 pounds.
• Visual: Clear vision for reading and inspections.
• Hearing Clarity: Ability to hear conversations in person or in virtual communications

• Health Center/Clinic: Work within a healthcare facility, interacting with patients and staff.
• Outreach: Outreach work within community and field setting, engaging with underserved and at-risk communities.
• Remote: Home or remote office, using virtual communication to collaborate and interact with patients and staff.
• Moderate-Paced: Dynamic environment that requires both productivity and accuracy to reach goals and project objectives.
• Office Hours: Standard business hours, with occasional extended shifts based on clinic needs.

• High school diploma or equivalent is required.
• Associate or bachelor’s degree in social work, public health, human services, or other related field is preferred.

• 2+ years in a healthcare or customer service setting preferred.
• A valid government-issued photo identification document is required.
• A valid New York State driver’s license in compliance with FLCH driver’s policy is required.
• Current New York State automobile insurance in compliance with FLCH underwriting agreement is required. Policy limits should reflect $100,000/$300,000/$100,000 coverage.
• Applies working knowledge of community health principles in outreach and support programs.
• Able to collaborate across roles to achieve shared outcomes.
• Uses judgement to adapt communication style to various audiences and situations.
• Applies sound reasoning while analyzing problems and implementing effective solutions

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