Care Manager – Social Work – Hybrid

Care Manager – Social Work – Hybrid

Description

We’re committed to bringing passion and customer focus to the business.

Job Description:

The ​Care Manager is responsible for providing care management for a specific risk stratified group of patients that is intensive, ongoing, and specific to meeting their complex needs. This position requires a comprehensive approach to healthcare delivery that focuses on coordinating and optimizing services for individuals with multiple, chronic, and often interrelated medical, social, and behavioral health needs.

Essential Functions:

• Conduct thorough assessments of patients’ physical health, mental health, cognitive functioning, social support systems, and living environments.
• Develop personalized care plans tailored to address each patient’s unique needs and goals, incorporating input from healthcare providers, family members, and the individuals themselves.
• Facilitate communication and collaboration among healthcare providers, including physicians, nurses, therapists, pharmacists, and specialists, to optimize care delivery and prevent gaps or duplications in services, including Care Rounds, or similar type meeting, at the practice to collaborate on care plans and strategies.
• Actively engage primary care providers and practice staff in identifying complex members and collaborate with providers and care teams on methods for navigating members’ care successfully along the care continuum.
• Complete visits with members, their caregivers, and significant others in a variety of settings, determined by program models and initiatives, including the practice, home, and/or facilities.
• Provide patient-centered care management for all transitions of care for patients that move from one healthcare setting to another or from one level of care to another, including medication reviews, evaluation of needs, identification of support services, and coordination with the primary care provider.
• Providing patients and caregivers with education and resources to better understand their health conditions, medications, and self-care strategies, empowering them to actively participate in their own care and improve health outcomes.
• Promote self-management skills and empower patients to actively participate in their own care, fostering independence and autonomy whenever possible.
• Maintain accurate and up-to-date documentation of all assessments, care plans, interventions, and outcomes in electronic health records and other relevant systems utilizing PHP Care Management standard operating procedures.  
• Regularly monitoring patients’ progress and outcomes, conducting follow-up assessments, and adjusting care plans as needed to ensure that patients receive timely, appropriate, and high-quality care.

Knowledge, Skills and Abilities:

• Experience with assisting patients through transitions on the care continuum.
• Experience with conducting assessments of patients’ physical health, mental health, cognitive functioning, social support systems, and living environments
• Experience managing complex physical and behavioral needs of patients and families
• Knowledge of case management, community resources/agencies, program and workflow development, and process improvement.
• Accept and work with diverse populations (age, ethnic groups, socio-economic levels, etc.) and provide culturally sensitive coaching, education and assistance to members and their families.
• Ability to collaborate and resolve community resource issues in a creative, positive, and timely manner to improve clinical outcomes of members.
• Skills in Motivational Interviewing.
• Proficiency in computer skills and electronic health record systems for documentation and communication purposes
• Perform intermediate level of competence with various computer software applications including MS Outlook, Word, Excel, and Power Point.

Qualifications:

• Licensed Clinical Social Worker (LCSW), Licensed Social Worker (LSW), Master’s in Social Work (MSW) or equivalent professional designation (preferred). (Required Licensure or Certification for this position must be maintained by the employee as defined by the company policies and procedures)
• Minimum of 1-2 years of experience in healthcare, case management, or care coordination.
• Preferred: Bilingual in English and Spanish to effectively communicate with Spanish-speaking patients and families.
• Home office that is HIPAA compliant for all remote or telecommuting positions as outlined by the company policies and procedures.

If you like wild growth and working with happy, enthusiastic over-achievers, you’ll enjoy your career with us!

Benefits

Not Specified