Re-Entry Case Manager at Primary Health Solutions

Description

Case Manager

Department: Administration

Reports To: Clinic Operations Director

FLSA Classification: Exempt

Last Updated: Feb 2025

About Primary Health Solutions

Our Mission

We meet people where they are and partner with them on their journey towards wellness.

Our Vision

The destination for servant leaders to provide comprehensive and exceptional care.

Our Values

R – Respect

I – Innovation

S – Stewardship

E – Excellence 

Case Manager Summary

The Case Manager will facilitate the transition of individuals from jail to the community, focusing on 

connecting them to primary care and addressing healthcare needs. They will coordinate care, assist 

with navigating the healthcare system, and address social determinants affecting reintegration. This 

role ensures access to medical, medication, behavioral health, and social services post-incarceration. 

Additionally, the Case Manager embodies PHS’ RISE values in interactions with patients and staff.

A Day in the Life

This job description reflects management's assignment of essential functions. Nothing in this job 

description restricts management’s right to assign or reassign duties and responsibilities to this job 

at any time. 

• Facilitate care coordination for patients transitioning from jail or other community institutions, ensuring they are linked to primary care services immediately upon release.
• Complete intake assessments for individuals leaving jail to identify their medical, mental health, and social needs.
• Develop and implement individualized care plans in collaboration with PHS care team and community partners.
• Schedule and coordinate appointments for patients needing medical care, mental health services and other specialty care.
• Monitor patient progress and provide regular follow-up to ensure adherence to care plans, medications and treatment recommendations.
• Provide benefit coordination including assistance in enrolling into state and federal benefits e.g., Medicaid
• Connect patients to community resources such as housing, transportation, food assistance, substance use treatment and other wrap-around services.
• Maintain accurate documentation of all interactions, care plans, and patient progress in the patient tracking system.
• Work with correctional facilities, probation officers, and other community organizations to ensure seamless service coordination and care delivery.

Core Competencies

• Making Complex Decisions: decision quality
• Taking Initiative: action-oriented
• Influencing People: communicates effectively, drives engagement
• Being Authentic: instills trust
• Being Open: demonstrates self-awareness, self-development
• Being Flexible and Adaptable: being resilient and nimble learner 

Requirements

Success Requirements

To perform this job successfully, an individual must be able to perform each essential duty 

satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability 

required. Reasonable accommodation may be made to enable individuals with disabilities to perform 

the essential functions.

Education/Experience

Bachelor’s degree in social work, Nursing, Psychology, or a related field is required. A minimum of 2 

years of case management experience is required, preferably in a healthcare or social services setting. 

Experience working with individuals transitioning from the criminal justice system (e.g., jail or prison) 

is strongly preferred. Knowledge of benefit coordination, community resources, and behavioral 

health care services is preferred.

Language Skills

Ability to communicate effectively with individuals from diverse backgrounds, including those with 

varying literacy levels and cognitive abilities. Proficiency in written and verbal communication, 

including the ability to write clear, concise case notes and progress reports.

Reasoning Ability

Ability to solve practical problems and deal with a variety of concrete variables in situations where 

only limited standardization exists. Ability to analyze complex situations, assess patient needs, and 

devise effective care plans. Strong problem-solving skills, with the ability to work independently and 

make decisions to meet patients' needs in a timely manner. Ability to adapt to changing 

environments and effectively handle emotional or crisis situations with patients.

Computer Skills

To perform this job successfully, an individual should have the ability to gain knowledge to be 

proficient of current electronic health record, practice management system and Microsoft 365 

including Outlook, Excel and Word. 

Other Applicable Requirements

Strong communicator and listener to patients and associates. Strong interpersonal skills (friendly, 

caring, patient). Strong verbal/written communication skills. Strong organizational skills and attention 

to detail. 

Physical Demands

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 stand, walk, use hands 

to finger, handle, or feel; reach with hands and arms and talk or hear. The employee is occasionally 

required to sit and stoop, kneel, crouch, or crawl. The employee must regularly lift and /or move up to 

25 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral 

vision, depth perception and ability to adjust focus.

Work Environment

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. While performing 

the duties of this Job, the employee is occasionally exposed to fumes or airborne particles; toxic or 

caustic chemicals and risk of radiation. The noise level in the work environment is usually moderate.

Affirmative Action/EEO Statement

It is the policy of Primary Health Solutions to provide equal employment opportunities without 

regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, sexual 

orientation, genetic information or any other protected characteristic under applicable law.

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of 

activities, duties or responsibilities required of the employee for this job. Duties, responsibilities, and 

activities may change at any time with or without notice