Care Manager

Care Manager

Requirements

• Master’s Degree in Social Work from an accredited program
• Current RN license and BSN
• Colorado: Current valid LCSW license or SWC or LSW required at hire with LCSW required within 3 years of employment
• Montana: Current valid LMSW or LCSW license or SWLC required at hire with LCSW required within 4 years of employment or LMSW required within 3 years of employment
• Two (2) years of experience as a Social Worker in a community, outpatient, or acute care setting
• Knowledge of Medical Terminology
• Knowledge of Desktop software including Microsoft or Google applications
• Ability to Navigate an Electronic Health Record
• Knowledge of Post-acute Skilled resources

Responsibilities

• Identifies patients for proactive intervention using payor models, medical, and social determinants of health risk criteria
• Coordinates the care and services for patients identified as needing assistance or meeting Care Management criteria
• Collects in-depth information about a patient’s condition, situation and functioning to identify individual needs in order to develop a discharge plan to meet those needs
• Works with patients and family/caregivers, and/or care representatives to determine specific goals and actions based on assessment
• Coordinates discharge planning
• Executes specific interventions to meet established goals
• Organizes, integrates, and coordinates the necessary resources to accomplish the goals and plan
• Assesses the patient’s prior level of functioning, access to and/or use of community resources, psychosocial needs, and available support systems
• Assists the care team in developing a plan of care which includes but is not limited to: assuring appropriateness of services and care setting, assuring individualized support and education, determining the need for continued services, planning for discharge, and identifying and connecting patients/families and/or care representatives with available community resources if needed
• Collaborates with Physicians and other members of the health care team on the patient’s behalf
• Assesses and coordinates care for patients with complex social determinants of health needs and complex family dynamics
• May provide crisis counseling, behavioral health, or substance abuse counseling and interventions per care site resources
• Identifies appropriate admission and continued stay issues
• Enhances the quality of patient care through effective and efficient use of resources
• Collaborates with the care team to identify strategies for appropriate reduction in service utilization
• Monitors efficiency and availability of services and evaluates outcomes through variance tracking and data collection
• Uses criteria to implement strategies to resolve controllable variances
• Attends, facilitates and participates in rounds and case conferences
• Advocates for patient rights
• Identifies needs, facilitates, or provides education to physicians and ancillary departments/nursing units regarding care management, discharge planning process, and roles
• Participates in multidisciplinary groups and development of guidelines
• Collaborates with payors and outside agencies to promote a patient-centered care delivery system
• May be required to work days, evenings, weekends, and holidays
• Promotes mission, vision, and values of SCL Health, and abides by service behavior standards
• Performs other duties as assigned

Preferred Qualifications

• Five (5) years of social work experience is preferred