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Case Manager, Immigrant and Refugee Health Center

Location: Boston, MA
Post Date: 10/12/2021
Boston Medical Center (BMC) is more than a hospital. It's a network of support and care that touches the lives of hundreds of thousands of people in need each year. It is the largest and busiest provider of trauma and emergency services in New England. Emphasizing community-based care, BMC is committed to providing consistently excellent and accessible health services to all-and is the largest safety-net hospital in New England. The hospital is also the primary teaching affiliate of the nationally ranked Boston University School of Medicine (BUSM) and a founding partner of Boston HealthNet - an integrated health care delivery systems that includes many community health centers. Join BMC today and help us achieve our Vision 2030 which is a long-term goal to make Boston the healthiest urban population in the world.

Position: Case Manager, Immigrant and Refugee Health Center

Department: General Internal Medicine

Schedule: Full Time


The Immigrant and 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)), OB/GYN (Refugee Women's Health Clinic (RWHC)) 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 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 serving as a key member of the IRHC Mobile Response Team (which allows the IRHC to engage patients wherever they are across the hospital for support and connection to culturally responsive immigrant 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 the BMC health system and 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 experience working with vulnerable immigrant and refugee populations, including those with trauma history and complex social and socioeconomic needs. Preference given to candidates who are bilingual and to those with connections to immigrant communities and lived experience as an immigrant to the United States.


  • Conducts Immigrant and Refugee Health Center (IRHC) Needs Assessment/Intake for 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

  • Serve as a key member of the IRHC Mobile Response Team (MRT)
    • 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 IRHC 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.

(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).


Masters' degree in social work (MSW) or counseling preferred, or Bachelor's degree in social work or related human services field with minimum 3 years relevant experience.


  • 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, including lived experience as immigrant to the United States.
  • 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
  • Preference for candidates who are bilingual in English and Dari, Pashto, Haitian Creole, Spanish, Somali, Arabic, or French.


Competencies, Skills and Attributes

  • 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)
  • Familiarity with trauma-informed approaches
  • Knowledge of resources available to immigrant and refugee populations

Req id: 20793 Apply
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