Social Work Care Manager

Job Summary: The Social Work Care Manager (LSW) is responsible for coordinating screening and providing interventions to patients with identified complex chronic care. Functions in the capacity of a connector between the patient and the resources provided by the care management program. Supports whole health outcomes and communicates progress to those in the healthcare organization as well as ensuring the patients receive the best possible care.

Essential Duties and Responsibilities:

• Maintain patient care hours per week at designated site as determined by Director of Care Management.
• Provide consultation and academic support to physicians in the areas of biopsychosocial care coordination that may affect overall health outcomes including social drivers of health, substance use, and mental health concerns.
• Participate fully in relevant quality assurance and performance improvement measures.
• Provide comprehensive consultation regarding assessment and treatment options for metabolic condition management and mental/behavioral health to established patients.

o Assess patient and/or family biopsychosocial situations that result in diagnostic conclusions that include development concerns, family dynamics and stressors, and DSM V diagnoses.

o Develop and execute an individualized care plan (including medication reconciliation) alongside patients deemed high-risk, in collaboration with family/caregivers, physicians, nursing staff, and other professional staff.

o Document data, assessment, care plan, and expected outcome in electronic medical record.

o Review and update care plan based on risk-determined calendar cycle (e.g. every 30 days).

o Maintain as near to, and no more than, a full caseload as defined by manager and program requirements. Enroll new patients in a timely fashion per program requirements. Identify and follow-up on all referrals made to assure continuity of care and patient/family needs are met.

• Identify and follow up on all referrals made to assure continuity of care and patient/family needs are met.
• Complete condition-specific education as necessary with patient and patient family/caregiver. For chronic conditions such as hypertension, diabetes, heart failure, or severe mental illness, care manager (CM) conducts thorough assessment and education appropriate to scope of CM's licensure with patient, including checks for understanding, appropriate SMART goal setting, and referrals to other sources for

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ongoing education as needed (including referrals to primary care, specialists, behavioral health, collaboration with team nurses, group visits, medical education appointments).

• Communication with providers and care team regarding patient progress and care needs.
• Complete visits to home, skilled nursing facility or hospital as needed and determined by the care team.
• Participate in individual and group supervision monthly.
• Perform any crisis intervention, individual support, family support, and/or advocacy that is needed for the patient. This includes telephone triage for patient's presented routine, urgent, and emergent health concerns, and creating safety plans as needed.
• Performs other duties as assigned, including additional assessment, clinical, or administrative support for sub-populations and/or funder requests, according to manager assignment.
• Support transitions of care follow-up with patients, including contact during admission and coordinating post-discharge care at medical home and with specialists, medication, and/or durable medical equipment.
• The social-work prepared CM may also perform duties as assigned, such as

A. Following PCC workflows, the social-work prepared CM may conduct behavioral health encounters to support specific populations, according to manager assignment.

B. Social-work prepared CM may support group medical visits, including but not limited to VeggieRx.

C. Social-work prepared CM may complete additional assessment, clinical, or administrative support for sub-populations and/or funder requests, according to manager assignment

Basic Qualifications:

Experience:

• Master's degree in social work from an accredited university.
• 2 - 3 years clinical experience preferred.
• 2 - 3 years EMR experience preferred.
• Demonstrated skills in the designated and certified clinical area of practice arena and the ability to work and collaborate on a health care team.
• Demonstrated ability to effectively and efficiently handle a demanding workload involving multiple tasks.
• Proficient in MS Office Business Application including Outlook, Word, PowerPoint, Excel, and Teams.

Certifications/Licenses:

1. Current and valid CPR certification.

2. Social Worker - LSW required or plan to obtain within 90 days.

a. LCSW is not required.

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Physical Demands:

• Must be able to remain in a stationary position 50% of the time.
• Must be able to move around the clinic site 50% of the time.
• Constantly operates a computer, computer printer, copy machine, and telephone.
• Occasionally positions self to maintain exertion of physical strength to move objects of 10 pounds from one level to another.
• Must be able to transport from one site to another.
• Must be able to cover other shifts as necessary.

Other Skills

• Ability to read and write proficiently using the English language.
• Exchanging accurate information in communication with patients, families, and other healthcare providers.
• Follow-through, assumption of responsibility, and good judgment.
• Maintain professionalism under stressful situations.
• Self-motivated and directed with the ability to prioritize and work efficiently under pressure.
• Ability to understand and follow verbal and written communication.
• Detail-oriented with the ability to work with minimal/no supervision.
• Willingness to be part of a team-unit and cooperate in the accomplishment of departmental goals and objectives.
• Effective and creative problem solving.

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