Care Manager SW

3 weeks ago

Frederick, United States Frederick Health Full time

Job Summary

Supports, and is responsible for incorporating into job performance, the Frederick Health (FH) mission, vision, core values and customer service philosophy and adheres to the FH Compliance Program, including following all regulatory requirements and the FH Standards of Behavior.

The Care Manager Social Worker works collaboratively with medical providers and healthcare professionals within Frederick Health and across the healthcare continuum. Professional social work skills are utilized to assess for unmet social needs, provide information and referrals to appropriate resources, psychosocial assessment, counseling support, and establishing plans for management of identified needs in the acute and/or ambulatory setting. Assessment, planning, interventions, and reassessment are performed within a collaborative and interdisciplinary team. The Care Manager Social Worker will also assist with patient/family navigation through the healthcare continuum, while focusing on improving quality outcomes and ensuring appropriate utilization of resources through effective care management practices.

Example of Essential Functions:

Delivery of care coordination within Frederick Health which may include hospital or ambulatory site assignment. Performs psychosocial assessment and planning to develop the plan of care to address identified needs. Identification of barriers to care including but not limited to socioeconomic status, unmet social needs, impaired coping, support network dysfunction. Promotes and values diversity to promote inclusive working relationships. Communication with interdisciplinary care team, patients, and families Promotes coordination with healthcare professionals. Monitors and evaluates care management plans. Provides education. Possesses working knowledge of regulatory components of assigned healthcare setting.

Required Knowledge, Skills, and Abilities:

Demonstrates effective interpersonal and communication skills, including superb customer service skills. Strong organizational and time management skills Excellent critical thinking skills, ability to work in a fact pace team environment, ability to multi-task, ability to adapt well to change and take on new challenges/projects, ability to effectively communicate and collaborate with physicians and staff. Ability to apply creative problem-solving skills to complex situations. Knowledge of clinical and psychosocial aspects of patient care Community resource knowledge Ability to work independently and interdependently. Personal creditability and the ability to serve as both a patient advocate as well as being committed to the health system goals. Upholds social work values, ethical principles, ethical standards Demonstrates skills in planning, organizing, and managing multiple functions and complex processes. Knowledge of basic computer software programs

Minimum Education, Training, and Experience Required:

Graduation from an accredited school of social work with a Bachelors or Master’s degree in social work with a current Maryland license. Master’s Degree preferred. Three to five years of care management and/or healthcare experience. Care Management certification preferred including but not limited to Accredited Case Manager (ACM) certification. Certified in Cardiopulmonary Resuscitation (CPR) Completes Maryland Board of Social Work continuing education (CEU) requirements to ensure licensure is in good standing.

Patient Contact

Must demonstrate and maintain current knowledge and skills in providing appropriate care/contact for patients in the following age groups:

_X_Neonate (0 thru 30 days) _X_Infant (31 thru 12 months) _X_Child (13 months thru 12 years) _X_Adolescent (13 years thru 17 years) _X_Adult (18 years thru 65 years) _X_Geriatric (66+ years)

Physical Demands:

Light Work - Lifting up to 20 pounds on an infrequent basis (less than one lift every three minutes and/or carrying up to 10 pounds, or requiring walking or standing to a significant degree (about six [6] hours a day).

Ergonomic Risk Factors:

Repetition:Repeating the same motion over and over again places stress on the muscles and tendons.The severity of risk depends on how often the action is repeated, the speed of the movement, the required force and muscles involved.

Awkward Posture:Posture is the position your body is in and its effect on the muscle groups that are involved in the physical activity.Awkward postures include repeated or prolonged reaching, twisting, bending, kneeling, squatting, working overhead with your hands or arms, or holding fixed positions.

Working Conditions:

Bloodborne Pathogens Exposure Risk: Category B – MAY have exposure to blood or body fluids.

Reporting Relationship:

Reports to Department Manager

Care Management Department Summary

Integrated Care Management

The Integrated Care Management- Care Manager Social Worker will work collaboratively with physicians, staff, and other healthcare professionals within ambulatory Frederick Health Medical Group practices and/or community practices that participate in the clinically integrated network (CIN)- Frederick Integrated Healthcare Network (FIHN). Care coordination will focus on requirements of various value-based care contracts and population health focus areas. Transitions of care, risk stratification data, and provider/care team referrals will initiate care management within this population. The Care Manager Social Worker will interpret data to evaluate and implement care management strategies and interventions related to attributed beneficiaries and patient populations. Optimizes patient wellness through the promotion of self-management strategies. Telephonic, medical office, and home visits will be conducted.

Transitional and Chronic Care Management Program

The Transitional and Chronic Care Management (TCCM) Social Worker will work collaboratively with the TCCM clinicians, community programs and Frederick Health Hospital case managers.Social worker will focus on patient needs to ensure a healthy environment in their home and to be able to age in place as the goal.Optimize patient wellness through the promotion of self-management strategies.Work with FHH case managers on patients with contracts who DC to the community to ensure timely follow-up and make plans for when contract ends. Telephonic and home visits will be conducted. Behavioral Health Social Worker will concentrate on managing patients needing assistance with mental health and substance abuse issues to ensure optimal outcomes for the patients in the community.

Comprehensive Care Center

The Comprehensive Care Center (CCC) Care Manager works collaboratively with practice providers, staff, and other healthcare professionals to provide care coordination across the healthcare continuum. The social worker will assist the patient and their family in identifying barriers to medical care and helping to implement solutions and is responsible for connecting patients to required medical services and community resources. The social worker assists CCC patients in navigating the healthcare continuum while improving the coordination of care focused on enhancing quality outcomes while ensuring appropriate utilization of resources through effective care management practices. CCC SW will proactively identify opportunities to improve the patient and family experience of care and improve the efficiency and effectiveness of resource use.

Care Management-Inpatient

Care Management-Inpatient – The SW Care Manager, in partnership with physicians, nursing and healthcare team members, utilize professional skills to screen for and assess patient and family needs for care coordination, discharge/transition planning, risk stratification and psychosocial needs.The SW Care Manager role also includes proactive, individualized planning for patients’ progress across the continuum that optimizes quality of care, patient satisfaction, and utilization and reimbursement to meet organizational strategic objectives.

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