Social Work Care Manager

Job Summary:  The MHN Clinical Care Coordinator is responsible for coordinating screening and providing the intervention of patients with identified complex chronic care needs. Functions in the capacity of a connector between the patient’s needs and the resources provided by the care management program. Supports whole health outcomes and communicates progress to those in the healthcare organization as well as ensuring the patients receive the best possible care.

Essential Duties and Responsibilities:

• Maintain patient care hours per week at designated site as determined by Director of Care Coordination.
• Provide consultation and academic support to residents and attending physicians in the areas of bio psycho social care coordination that may affect overall health outcomes including social determinants of health, substance use and mental health concerns.
• Participate fully in relevant quality assurance and performance improvement measures.
• Provide comprehensive consultation regarding disease management assessment and mental/behavioral health treatment options to established patients.
• Assess patients’ and/or families’ bio-psycho-social situations that result in diagnostic conclusions that include development issues, family dynamics and stressors, and a DSM IV multi-axial diagnosis.
• Develop and execute an individualized care plan (may include medication reconciliation) for high-moderate risk patients/family and other patients referred to you in collaboration with physician, nursing staff, other professional staff and input from patient.
• Document data, assessment, care plan and expected outcome in electronic medical record.
• Review and update care plan based on risk-determined calendar cycle (e.g. 30 days for high risk). 
• Maintain as near to, and no more than, a full case load as defined by manager and program requirements. Enroll new patients in a timely fashion per program requirements.
• Identify and follow-up on all referrals made to assure continuity of care and patient/family needs are met.
• Complete disease specific education as necessary with patient and patient family. For chronic conditions such as hypertension, DM, CHF/CAD, and stroke & rehabilitation, or SMI, CCC conducts thorough assessment and education appropriate to scope of CCC’s licensure with patient, including checks for understanding, appropriate SMART goal setting, and referrals to other sources for ongoing education as needed (including referrals to PCP, specialists, BH, collaboration with team RNs, group visits, medical education appointments).
• Communication with providers and care team regarding patient progress and care needs.
• Complete home visits, or visits to skilled nursing facility or hospital as needed and determined by the care team.
• Participate in individual and group supervision monthly.
• Perform any crisis intervention, individual counseling, family counseling, advocacy that is needed for the patient. This includes telephone triage for patient’s presented routine, urgent, and emergent health concerns, and creating safety plans as needed.
• Performs other duties as assigned.
• The social-work prepared CCC may also perform duties as assigned, such as

1. Following PCC workflows, social-work prepared CCC may conduct behavioral health encounters to support specific populations, according to manager assignment.
2. Social-work prepared CCC may support group medical visits, including but not limited to Veggie RX.
3. Social-work prepared CCC may complete additional assessment, clinical, or administrative support for sub-populations and/or funder requests, according to manager assignment

Basic Qualifications: 

         Experience: 

• Masters Degree in Social Work from an accredited University.
• English or Spanish speaking (preferred)
• 2 – 3 years clinical experience preferred.
• 2 - 3 years EMR experience preferred.
• Constantly communicates with patients, families, and other healthcare providers. Must be able to exchange accurate information in these situations.
• Demonstrated skills in the designated and certified clinical area of practice arena and the ability to work and collaborate on a health care team. 
• Demonstrated ability to effectively and efficiently handle a demanding workload involving multiple tasks.
• Proficient in MS Office Business Application to include: Outlook, Word, PowerPoint and Excel

• Certifications/Licenses:

• Current and valid CPR certification
• Masters Degree in Social Work from an accredited University
• LSW (Licensed Social Work)
• Prefer 2-3 years of Clinical and EMR experience
• Prefer bilingual, Spanish language fluency 

         Physical Demands

• Must be Hybrid/In Person and Remote

• Must be able to remain in a stationary position 50% of the time.
• Must be able to move around the clinic site 50% of the time.
• Constantly operates a computer, computer printer, copy machine, and telephone.
• Occasionally positions self to maintain exertion of physical strength to move objects of 10 pounds from one level to another.
• Ability to move as needed to perform necessary nursing skills such as wound care, injections, and other procedures. Must be able to transport from one site to another.
• Must be able to cover other shifts as necessary.

         Other Skills

• Ability to read and write proficiently using the English language.
• Constantly communicates with other healthcare providers. Must be able to exchange accurate information in these situations.
• Follow-through, assume responsibility and use good judgment. 
• Maintain professionalism under stressful situations. 
• Self-motivated and directed with the ability to prioritize and work efficiently under pressure.
• Ability to understand and follow verbal and written communication. 
• Detail oriented with the ability to work with minimal/no supervision.
• Willingness to be part of a team-unit and cooperate in the accomplishment of departmental goals and objectives.
• Effective and creative problem solving.