Community Care Manager

1 week ago

Annapolis, Maryland, United States Luminis Health Full time
Job Title: Community Care Manager

At Luminis Health, we are seeking a highly skilled and compassionate Community Care Manager to join our team. As a Community Care Manager, you will play a vital role in ensuring that patients receive high-quality, coordinated care across the healthcare continuum.

Key Responsibilities:
  • Function as a subject matter expert in identifying social determinants of health and optimal community resources to support high-risk patients.
  • Assist patients through the healthcare continuum as a patient advocate, navigator, and liaison to the care team, providers, and community resources.
  • Provide leadership to the care team to improve care, community resource coordination, and manage referral processes.
  • Facilitate health and disease patient education and support patient self-management of disease and behavior modification interventions.
  • Collaborate with patients, care team, and providers to understand patient short and long-term goals and contribute to patient longitudinal plan of care.
  • Coordinate continuity of patient care with providers across the healthcare system, including post-hospital or ED discharge.
  • Use high-risk screening criteria to identify and manage high-risk patients, including patients with multiple comorbidities or at risk of avoidable utilization/readmission.
  • Participate on teams for data collection, health outcomes reporting, clinical audits, and programmatic evaluations related to the Maryland Primary Care Program (MDPCP), and quality improvement initiatives.
  • Evaluate the psycho-social clinical plan of care, resource utilization, and contribute to the development of new tools, forms, and procedures.
  • Contribute to the performance evaluation of care team members.
Requirements:
  • Master's degree with a focus in social work. LCSW-C required (or obtained within 6 months of employment).
  • At least 5 years of experience in healthcare with care management experience.
  • Required License/Certification: Licensed Certified Social Worker (LCSW) or Licensed Certified Social Worker Clinical (LCSW-C) from the Maryland Board of Social Work Examiners or other approved designated Social Worker license/certification. If Licensed Certified Social Worker (LCSW) must obtain Licensed Certified Social Worker Clinical (LCSW-C) within 6 months of hire.
  • Current American Health Association Health Care Provider Basic Life Support (BLS) CPR certification.
  • Case Management Certification strongly preferred.
Benefits:
  • Medical, Dental, and Vision Insurance.
  • Retirement Plan (with employer match for employees who work more than 1000 hours in a calendar year).
  • Paid Time Off.
  • Tuition Assistance Benefits.
  • Employee Referral Bonus Program.
  • Paid Holidays, Disability, and Life/AD&D for full-time employees.
  • Wellness Programs.
  • Eligible for shift differentials/OT.
  • Eligible for commitment bonus.
  • Employee Assistance Programs and more.

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