Social Work Care Manager (Dsnp)

SUMMARY

The Social Work Care Manager for Belong Health's DSNP program is responsible for providing comprehensive, member-centered care management services for Medicare beneficiaries with complex medical, behavioral health, and social needs. This role applies care management principles to assess member needs, develop and implement individualized care plans, coordinate services across the continuum of care, and maintain collaborative relationships with provider practices, community-based organizations, caregivers, and the Belong Health team. The Social Work Care Manager utilizes expertise in behavioral health, psychosocial assessment, crisis intervention, motivational interviewing, and care coordination to identify and address barriers to care, support member engagement, and ensure medical, behavioral health, and social determinants of health needs are integrated into a comprehensive plan of care.

ESSENTIAL JOB DUTIES AND RESPONSIBILITIES

• Responsible for providing comprehensive care management services to Medicare beneficiaries with complex medical, behavioral health, and social needs.
• Orient new members to the Belong Health DSNP program and educate members and/or caregivers on care management services.
• Advocate, empower, inform, and educate beneficiaries on self-management techniques, behavior change strategies, and available community resources.
• Conduct comprehensive biopsychosocial assessments to identify barriers to care, unmet needs, and opportunities for intervention.
• Complete health risk assessments, reassessments, psychosocial evaluations, and other assessments in accordance with program requirements.
• Identify members requiring intensive care management interventions and coordinate appropriate clinical, behavioral health, social service, and community-based supports.
• Develop and implement an Individualized Care Plan (ICP) that addresses medical, behavioral health, and social determinants of health needs.
• Monitor member progress toward care plan goals and revise interventions based on changing clinical, behavioral health, or social needs.
• Lead and participate in interdisciplinary care team meetings.
• Collaborate with providers, social workers, discharge planners, behavioral health professionals, caregivers, and community-based service providers to coordinate care and achieve care plan goals.
• Support transitions of care activities, including post-discharge outreach, assessment of psychosocial needs, medication reconciliation support, and coordination with providers and caregivers.
• Provide crisis intervention, behavioral health support, and resource navigation as appropriate within the scope of licensure and organizational protocols.
• Facilitate referrals and connections to behavioral health services, social services, financial assistance programs, housing resources, transportation services, and other community-based supports as appropriate.
• Document all care management activities in the appropriate system in accordance with internal policies and established documentation procedures.
• Work directly with members, their families and/or advocates, providers, and community service organizations on an ongoing basis to coordinate care and reduce barriers to care.
• Utilize population health, risk stratification, and care management technology platforms to prioritize outreach and interventions.
• Promote a culture of accountability and performance to both meet and exceed personal service vision goals and ensure timely and satisfactory resolution of highly complex, specialized, and non-routine member issues.
• Maintain knowledge of community resources, behavioral health services, and social support programs to effectively address member needs.
• Other duties as assigned.

SUPERVISORY RESPONSIBILITIES

This role does not have supervisory responsibilities.

REQUIRED PROFESSIONAL EXPERIENCE AND QUALIFICATIONS

• Current unrestricted license in a behavioral health discipline required, including LMSW, LCSW, LMHC, or equivalent licensure as permitted by state regulations.
• Advanced clinical licensure (e.g., LCSW) preferred.
• Working knowledge of Medicare and Medicaid programs and experience with regulatory requirements and reporting.
• Proficient in navigating multiple systems; demonstrated PC skills using Microsoft applications.
• Two (2) or more years' experience in a health plan, health care organization, Community Based Organization, behavioral health organization, or social services environment.
• Experience supporting Medicare, Medicare Advantage, Medicaid, Dual Eligible Special Needs Plans (D-SNP), or other complex populations.
• Experience delivering care management services in a telephonic and/or virtual environment.
• Understanding of the needs and dynamics of elder care services, disadvantaged, vulnerable, and disengaged populations.
• Knowledge of behavioral health conditions, substance use disorders, crisis intervention, psychosocial assessment, and trauma-informed care principles.
• Knowledge of care coordination, transitions of care, motivational interviewing, and person-centered care planning principles.
• Knowledge of social determinants of health and community-based resources available to support members with complex needs.
• Experience participating in cross-departmental projects and policy and procedure changes, including coordination of activities and initiatives across departments.
• Excellent customer service, active listening, issue assessment, trend identification, and analytical skills, with a demonstrated ability to problem solve effectively and efficiently.
• Commitment to high ethical standards in all work; protects the privacy of member and company data and exercises discretion in handling confidential member information.
• Excellent oral and written communication skills, including presentation skills.
• Strong organizational and follow-through skills.
• Demonstrated ability to manage a caseload of medically, behaviorally, and socially complex members.
• Ability to work independently and effectively within a fully remote and highly collaborative team environment.

PREFERRED PROFESSIONAL EXPERIENCE AND QUALIFICATIONS

• Demonstrated experience in a managed care, Medicare Advantage, D-SNP, C-SNP, Medicaid, or value-based care environment.
• Knowledge of community services and resources supporting older adults, individuals with disabilities, and underserved populations.
• Experience supporting members with serious mental illness (SMI), substance use disorders (SUD), or other complex behavioral health conditions.
• Experience coordinating care across medical, behavioral health, and community-based service settings.
• Bi-lingual Spanish speaking preferred.
• Multi-state licensure preferred.
• Experience working within interdisciplinary care teams.

EDUCATION AND TRAINING

• Master's degree in Social Work, Mental Health Counseling, or related behavioral health field required.
• Licensure as a Licensed Clinical Social Worker (LCSW), Licensed Master Social Worker (LMSW), Licensed Mental Health Counselor (LMHC), or equivalent behavioral health licensure required
• Additional state licensure may be required based on business needs.

LICENSE AND CERTIFICATION

• Active, unrestricted professional license in the state of practice required, including LCSW, LMSW, LMHC, or equivalent behavioral health licensure as permitted by state regulations.
• Ability to obtain and maintain licensure in additional states if required by business needs.

WORK ENVIRONMENT

The work environment characteristics described here are representative of those encountered while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually quiet. Most of the work is performed on a computer and in a sedentary environment.

TRAVEL

This role may require some travel based on business needs, including but not limited to traveling to semi-annual onsite meet ups.

SALARY RANGE

• $80,000-$95,000