The Social Work Care Manager will be responsible for contributing to the supporting care management for high-risk/complex patients in our ACO’s. This Social Worker will partner with the practice-based Care Managers and the patients to address complex needs and psychosocial barriers to care.
DUTIES AND RESPONSIBILITIES
- Perform Chronic Care Management support for a cohort of high-risk/complex patients across our ACO’s;
- Conduct a comprehensive evaluation of social and behavioral health needs;
- Identify socio-economic and other risk factors that may make compliance to treatment difficult for the patient;
- Assess the patient’s knowledge of their condition and health needs and provide education and self-management support based on the patient’s unique learning style;
- Collaborate with practice-based care manager to address barriers to care and promote adherence to a comprehensive care plan;
- Connect patients to relevant community support resources and follow through with coordination until patient fully connected;
- Provide support and counseling to patients with behavioral health needs, connecting to mental health resources as appropriate;
- Provide coaching to the practice-based care managers on management of complex patients and resource utilization;
- Coordinate patient care with multi-disciplinary teams including the primary care physician where appropriate;
- Utilize care management tools and resources to drive care management practice;
- Contribute to the ongoing improvement and development of the care management technology platform, helping to drive efficacy and functionality for users;
- Assist the Care Management Lead with all duties as appropriate and coordinate with other Aledade team members regularly.
QUALIFICATIONS:
REQUIRED
· Master’s degree in Social Work (MSW Preferred)
· 3-5 years of social work, preferably in healthcare case management, also involving care coordination with community-based agency, home health, ambulatory care, and across multiple settings with multiple providers
· Experience supporting highly complex patients with multiple psychosocial barriers to care
· Demonstrated compassion and cultural awareness, withholding judgment towards people’s vulnerabilities or unique circumstances. Able to positively influence others by exhibiting respect and consideration
PREFERRED
· Familiarity with the community we are serving or commitment to learn and understand through on the ground networking, community assessment, etc.
· Knowledge and experience coaching patients and teaching self-management skills
· Demonstrated experience and effectiveness in change agent role
· Experience working with vulnerable populations (geriatrics, minorities, etc.)
· Able to navigate ambiguity and adapt quickly to multiple demands and shifting priorities
· Open to change and able to modify approach in the face of changing conditions or unexpected obstacles
· Demonstrated strong time-management skills
· Exceptional communication skills, both written and oral
· Strong work ethic built on a foundation of proactivity, collaboration, and teamwork
· Experience working with Electronic Health Records and other healthcare technology
· Demonstrated ability to receive critical feedback to further growth and development
WORK ENVIRONMENT
The work of this position is an environmentally controlled office environment. The position requires the ability to work under pressure and with a diverse population, including staff, providers, clients, patients, insurance companies and other members of the public. The position may cause frequent exposure to communicable diseases, bodily fluids, toxic substances, medicinal preparations and other conditions common to a clinical environment.
THIS POSITION IS AN OSHA EXPOSURE CATEGORY I
Tasks that involve exposure to blood, body fluid, or tissues.
All procedures or other job-related tasks that involve an inherent potential mucous membrane or skin contact with blood, body fluids, or tissues, or a potential for spills or splashes of them, are Category I tasks.
POSITION REPORTS TO: Care Management Nurse Supervisor