Licensed Clinical Social Worker - Care Management

The Licensed Clinical Social Worker, Care Management, will work on a multidisciplinary healthcare team in a primary care/telephonic setting; focusing on coaching and coordination of care for patients needing navigation and addressing patient care needs and follow up after clinical care.  Responsibilities specific to Licensed Clinical Social Worker include providing observation, ongoing assessment, and therapeutic intervention consistent with physical and psychological status.   Awareness of services available to patients and their families is an important part of this assessment.
The Licensed Clinical Social Worker will identify the needs of patients at risk and assist the providers to develop processes for managing the patient’s preventative care, transitions of care, and or chronic disease management using defined protocols as well as their own sound judgement.  The Licensed Clinical Social Worker is a key role in the care coordination of patients attributed to value based contracts.           

Position Description                 

• Assess identified members to determine members appropriate for management early in their disease process and at any time during the continuum of care.
• Complete a comprehensive assessment to identify patient risk and develop a care plan utilizing expertise and judgement to evaluate needs for alternative services as needed.
• Assess members’ Social Determinants of Health, such as housing, food, transportation, and safety in the home.
• Work collaboratively with physicians and community resources including pharmacists, nurses, registered dieticians, and other disciplines to address patient needs as identified in assessments.
• Assess and screen members for behavioral health concerns (depression / substance abuse) utilizing screening tools, including the PHQ2 and 9 Depression screenings, and ensure they are receiving appropriate behavioral health interventions.
• Facilitate any necessary follow-up or referrals for behavioral health needs with local behavioral health providers.
• Develop, facilitate, and communicate a plan of care in partnership with the member, family (or designated representatives), providers, and multidisciplinary care team to assess the options of care including use of benefits and community resources.
• Update care plan to include progress towards achieving established goals and self-management activities.
• Coordinate necessary referrals and authorizations pertinent to patient care and well-being.
• Utilize developed systems, processes, and initiatives to engage patients in relevant social activities necessary to promote wellness and care at the right place and time.
• Facilitate member adoption of strategies to promote physician recommended behavior changes.
• Identify and utilize cultural and community resources and align with the patient’s cultural preferences as much as possible.
• Facilitate the information flow between health representatives and the care team.
• Coordinate care and communicate with multiple providers, internal and external to the practice.
• Act as a resource for both clinical and non-clinical staff [i.e., care coordinators, dieticians, RN Case Managers].
• Attend required training and collaboration sessions [i.e., learning sessions/ practice team meetings] as scheduled.
• Provide and facilitate open communication, regarding patient status, with physicians and patient care team.
• Develop constructive relationships with internal GLIN population health team members, participating providers, and community resources.
• Other job-related duties as assigned.
  

• Valid and current LCSW or LMSW licensure
• 3-5 years’ Care Management and/or managed care experience in one of the following settings: acute inpatient, rehabilitation, sub-acute, skilled facility, homecare, ambulatory Care Management, or managed health plan.
  

• Timely and accurate documentation of day-to-day activities in designated technology platform.
• Adaptable to new technologies and software.
• Proficiency in EMR system(s), Outlook and data entry experience preferred.
• Basic PC skills (MS Word/Outlook/PPT/Excel).
• Knowledge of Federal and State regulations for Medicare and Medicaid and other national and state funded programs.
• Knowledge of community resources access.

• Ability to use independent judgment and to manage and impart confidential information.
• Ability to analyze and solve problems; requires details, data and facts that must be analyzed and challenged prior to making decisions.
• Strong communication, listening interpersonal skills.
• Ability to clearly communicate medical information to professional practitioners and/or the public.

• Excellent organization, prioritization, follow up, analytical and time management skills with ability to handle multiple priorities and deadlines.
• Good interpersonal skills, sense of urgency, being proactive and ownership for one’s work.
• Dependable, with strong work ethic and extremely high degree personal integrity.
• Ability to deal with multiple interruptions on a continual basis that must be met with a friendly exchange with others.
• Ability to develop and implement new approaches to improve processes, procedures, or the general work environment.
• Ability to review critical issues, effectively solve problems and create action plans.