Position: LCSW Care Manager
Employee Category: Exempt
Reporting Relationship: Manager of Population Health
Requirements, Special Skills or Knowledge:
- Master of Social Work degree and at least two years of experience in care management in a community based social work, with health services care management preferred.
- Active LCSW License in good standing in the state of Oklahoma.
- Excellent oral and written communication skills.
- Bilingual (English/Spanish) preferred.
Alertness— Being aware of what is taking place around me, so I can have the right responses.
Dependability— Fulfilling what I consented to do, even if it means unexpected sacrifice.
Flexibility—Willingness to change plans or ideas without getting upset.
Sensitivity—Using my senses to perceive the true attitudes and emotions of others.
Summary of Duties and Responsibilities:
The LCSW Care Manager is responsible for all aspects of care for high risk members with chronic behavioral and/or health conditions, partnering with members and their caregivers, physicians and the health care team to provide timely access to ongoing and long term needed care, continuity of care across all settings, informed and shared decision making, and linkages to supportive services and community resources. This position works in collaboration with the HAN organization.
Primary Duties and Responsibilities:
Telephonic Care Management:
- Demonstrates and applies principles of person-centered, strength-based philosophy, motivational interviewing, shared decision making, health coaching and adult learning principles.
- Demonstrates a sensitivity and responsiveness to a variety of cultural values, beliefs and social determinants of health.
- Facilitates access to health care providers, staff and resources.
- Assists patients to utilize the Variety Care patient portal.
- Links patient and caregiver to supportive community services as needed.
- Helps facilitate communication between patients and their providers, and coordinates communication among all of the patient’s providers.
- Maintains accurate records to document and monitor the care coordination activities in the electronic healthcare record (EHR).
- Monitor and evaluate plans including progress toward goals, health status, medication reconciliation and member experience.
- Provide at least monthly contact with member via telephone calls and when appropriate:
- home visits to evaluate home environments and family relationships, and to provide support and self-management coaching, medical and psycho-social appointments, and hospital visits.
- Acts as primary liaison between staff and patients.
- Participates in regular case staffing meetings and reviews.
- Monitors identified performance measures and deliverables and provides regular progress reports. (Report submission will be determined as performance measures and deliverables are identified).
- Other duties as assigned.
Community and Clinic Based Care Management:
- Fulfills all tasks associated with Telephonic Care Management.
- Provides basic assessment of health and mental health status, functional abilities, caregiver stability, social supports, financial resources, environment and safety concerns, life care planning and self-management skills.
- Facilitates development of comprehensive shared plan reflecting patient goals and preferences, self-care, and evidence-based best practice for multiple chronic conditions.
- Provides a “patient friendly” version of integrated plan of care.
- Provides home visits and telephone contact commensurate with the patient’s health status to monitor and evaluate routine issues, provide disease management education, health coaching, and assess progress and response to their personal plan.
- Provides and coordinates transition services across all settings of care.
- Communicates care plan to all providers in all settings of care (ED, hospital, rehabilitation facility, home care, nursing home and specialists).
- Ensures patient, caregivers and providers receive timely information for treatment decisions across all settings.
- Coordinates/verifies that services, equipment and needed supplies are in place.
- Participates in team meetings to review individual and population-based outcomes, patient experiences, and identify opportunities for practice improvement.
- Communicates with other providers (e.g., specialists, respiratory therapists, nutritionists, physical therapists, home health providers, care managers, social workers) by optimizing the office-based care team to send, receive, and triage information flows among the providers.
- Serves as the Variety Care representative on community boards and task forces.
- Must be able to lift 25 pounds.