Care Manager (Community Care Team)- LSW, LSW-C, LMSW-CC or LCSW

Northern Light Maine Coast Hospital

Department: Community Care Team

Position is located: Ellsworth Family Practice

Work Type: Full Time

40 hours per week

Work Schedule: 8:00 AM to 5:00 PM

• Hybrid with approx. 75% of work remote and 25% travel and home visits in Hancock county and surrounding areas
• Monday to Friday, no weekends, no holidays, no call!
• PSLF (Public Student Loan Forgiveness) eligible
• Supervision provided

Summary:

Serves in an expanded clinical and care management role to collaborate with patients, Primary Care Providers, practice teams, and all community agencies, to provide care that ensures the delivery of quality, efficient, and cost-effective healthcare services. Assesses patient needs from a strengths-based perspective and understands environmental factors that impact health outcomes. Designs and implements coordinated intervention plans that optimize patient’s self-management of his/her health and life in ways that are fulfilling. The Social Worker works collaboratively within the Integrated Care Team. The expertise of the Social Worker is sought to assess and intervene with bio-psycho-social-spiritual barriers and to enhance patient engagement with the healthcare system in a manner that promotes optimal health. Utilizes evidence based shared decision-making models, brief treatment models, motivational interviewing, and other evidence-based interventions to encourage positive behavior change in order to assist patients to achieve their highest level of function.

Responsibilities:
1. Works as part of the Community Care Team, a specialty care management service within the larger Integrated Care Management team across the Northern Light Health system.

2. Assists to develop coordinated care plans for patients with complex medical and/or behavioral health needs. Fosters a team approach by working collaboratively with all practice and community-based team members.

3. Coordinates referrals between and among physical and behavioral providers to necessary and appropriate community resources to assist patients to meet their goals and improve functioning.

4. Adheres to system privacy standards while sharing timely clinical information with peers, providers and outside agencies to coordinate care.

5. Works closely with payers to appropriately apply member benefits and serve as a resource to the member and healthcare team.

6. Incorporates excellent written, verbal, and listening communication skills, positive relationship building skills, and critical analysis skills into social work practice.

7. Conducts assessments in a variety of settings, including, but not limited to telehealth (phone and video), primary care/other health offices, patient homes, hospital, or other community based setting, as deemed appropriate for each individual patient.

8. Develops collaborative relationships with community based agencies to understand and disseminate program and service eligibility, thus allowing for efficient use of referral systems aimed at improving care.

9. Utilizes appropriate conflict resolution, assertiveness, advocacy, brokerage, negotiation, and collaboration skills in facilitating patients’ movement throughout the health care continuum.

10. Completes mental health status exams and diagnostic interviews in accordance with evidence-based standards.