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Case Manager, Immigrant & Refugee Health Center

Location: Boston, MA
Post Date: 4/2/2020
The BMC Immigrant & Refugee Health Center (IRHC) Case Manager is responsible for supporting patients of the IRHC, which includes patients seen in any of the IRHC's specialty programs including in the departments of Psychiatry (Boston Center for Refugee Health and Human Rights (BCRHHR)), General Internal Medicine (Immigrant and Refugee Health Program (IRHP)) and other collaborating departments throughout BMC. The IRHC Case Manager will work with relevant stakeholders to identify and engage patients in case management with a focus on patient experience and improving health from a biopsychosocial perspective. They will be responsible for conducting the IRHC Needs Assessment/Intake for all new IRHC patients which includes comprehensive review of medical, mental health and social needs (legal, language, employment, transportation, etc.); for conducting mental health acuity assessments and triaging care appropriately; for running the IRHC Mobile Response Team (which allows the IRHC to engage patients wherever they are across the hospital for support and connection to immigrant-friendly care); for providing case management services including working with patients to identify strengths and barriers and facilitating referrals to appropriate medical/clinical providers and social services and resources; and for creating a nurturing warm, welcoming environment for new patients. The individual will comply with all data collection, data entry and data integrity needs both for facilitation of clinical care and reporting requirements to funders. The individual will collaborate with clinical staff, administrative staff and research personnel in the IRHC and all of its specialty programs, and will partner closely with IRHC front desk staff to appropriately welcome, evaluate and triage patients. Career development opportunities include participation in IRHC research and academic initiatives, participation in hospital-wide educational opportunities and providing teaching/trainings for hospital staff. Seeking someone with excellent interpersonal skills, critical thinking skills, and clinical experience working with vulnerable immigrant and refugee populations, including those with trauma history and complex social and socioeconomic needs.


  • Conducts Immigrant & Refugee Health Center (IRHC) Needs Assessment/Intake for all new potential clients. Includes:
    • Mental health acuity/crisis assessment, and facilitate appropriate triaging
    • Comprehensive assessment of client's medical, mental health and social needs
    • Collection of funder-required data points
    • Collaborate with front desk/administrative staff to schedule client for medical, mental health, social service appointments, as indicated by Needs Assessment
    • Appropriate documentation of needs assessment data in EMR

  • Pilot the IRHC Mobile Response Team (MRT), manage the MRT pager 9am-5pm
    • Respond to MRT pages during regular business hours; meet clients wherever they are at BMC to assess acute and high-level biopsychosocial needs and ensure client is successfully connected with appropriate resources, services and providers.
    • Actively participate in ongoing development and refinement of MRT model and processes in collaboration with IRHC teams
    • Provide consultation and recommendations to other hospital clinicians regarding resources and approaches to care for immigrant patients

  • Support Walk-In clients, as well as provide case management for established IRHC clients
    • Create a safe, warm, welcoming environment and encourage engagement in care
    • Provide case management services for small caseload of established IRHC clients, including connecting patients to a broad range of services including but not limited to: mental health services, primary care services, medical specialty services, immigration legal services, financial assistance, food, transportation, housing, clothing, health literacy, interpreter service needs, etc.
    • Provide client education regarding available services and resources both within the IRHC, throughout BMC and in community, and provide tools and facilitate connections to these resources
    • Facilitates interdisciplinary consultation on patient's behalf through participation in rounds, team meetings and clinical reviews
    • Maintains HIPAA standards and confidentiality of protected health information.
    • Performs and maintains all documentation in the electronic chart of patient encounters; resource development efforts; and other patient interventions and interactions

  • Program development and administrative responsibilities include:
    • Participates in multidisciplinary/staff/team meetings and activities; meets regularly with leaders at IHC and specialty programs to triage program issues appropriately.
    • Participates in team-based Quality Improvement (QI) initiatives
    • Participates in local site operations, including team operational meetings; and is actively engaged in developing, implementing and refining operational protocols and processes as IRHC infrastructure expands
    • Encouraged to engage in learning and growth opportunities including attending weekly Grand Rounds, and pursuing training opportunities with the approval of supervisor
    • Adheres to departmental/organizational policies and procedures.
    • Adaptable to changing programmatic needs
    • Performs other administrative functions as assigned by Manager/Supervisor
  • Must adhere to all of BMC's RESPECT behavioral standards

EDUCATION: Masters' degree in social work (MSW) required


  • Experience with mental health populations preferred; demonstrated ability to evaluate and appropriately triage mental health crisis situations
  • Experience with diverse immigrant and refugee populations preferred
  • Experience and comfort with risk assessment and appropriate triaging required
  • Comfortable innovating in information technology systems; experience using/documenting in electronic medical record systems
  • Experience in motivational interviewing is a plus


  • Ability to multitask, flexible, adaptable
  • Excellent interpersonal skills and ability to work collaboratively
  • Self-management skills, including ability to prioritize and set patient-centered goals
  • Excellent written and verbal communication
  • Able to maintain professional boundaries
  • Ability to work with diverse, safety-net population
  • Skilled at engaging difficult to engage patients—build rapport, trust
  • Creative problem solver
  • Ability to adapt to changes in healthcare delivery at local and systems level
  • Extensive knowledge of healthcare systems and community resources

    Ability to leverage systems and resources for improved patient outcomes

  • Strong organizational and time management skills
  • Willingness/ability to function in mobile role (walking around BMC campus)

Req ID: 14890