Care Manager-LCSW (CM-LCSW) will serve as a primary member of an interdisciplinary care team, focusing on improving the health status of individuals with medical, behavioral, and psychosocial issues. The CM-LCSW is a point of contact and advocate between the patient and the practice. CM-LCSW will apply clinical expertise to performing patient outreach, assessment, disease management, care coordination and care plan development for patients attributed across payors to Atlantic Medical Management (AMM), and its participating provider practices. The CM-LCSW implements practice-level population health models of care to improve patient outcomes. The CM-LCSW is responsible for encouraging patient and their identified support system participation in care and decision-making. This position requires the CM-LCSW to support to AMM goals and objectives in meeting performance targets for various initiatives, data analysis that supports care management, team development and other duties as assigned to support the development of the organization.
Responsibilities:
-Responsible for patient outreach, assessment, disease management, and care coordination to patients with high rates of medical and behavioral health utilization and/or psychosocial vulnerability
-Assess patients through telephonic and eventually face to face encounters
-Builds a collaborative relationship with patients and their identified support system to encourage care participation and improve self-management of needs
-Utilize motivational interviewing to identify barriers and facilitate care plan compliance
-Effectively educate patients about healthcare delivery, plan benefits and a variety of topics related to health, and community resources
-Coordinates timely and appropriate implementation of assessments, care plans, and interventions for the identified patient population
-Provide medication reconciliation and support ongoing adherence
Provide transitional care management
-Identify and helps to align patient care and community resources to prevent hospital readmissions and Emergency Department visits
-Document all activity in the documentation systems relevant to the role
-Collaborate with the care team to achieve high-quality, low-cost outcomes for patients.
-Interface and maintain positive relationships with key providers in the local hospitals, community practices, and organizations to ensure proper patient engagement and follow up
-Achieve established productivity targets
-Maintain compliance with the organization policies and procedures
-Demonstrate the ability to adapt, innovate and lead in a fast-paced environment, where change is common
-Passionate about making a difference in individual’s lives
-Other duties as assigned
Qualifications:
-Must have a current FULL licensure as a LCSW by the NC Social work Certification and Licensure Board
-Requires a Master’s in Social Work
-Two years post master’s clinical experience is required
-Knowledge of care management and quality principles are preferred
-Requires the ability to maintain confidentiality
-Must be able to interact with individuals of all cultures and level of authority
Knowledge, Skills and Abilities:
-Excellent interpersonal and communication capabilities (written and verbal)
-Proficient in MS Word, Excel, PowerPoint and Outlook software programs
-Familiar with clinical care and disease processes
-Dependable, manages time well and is efficient
-Strong organizational skills and ability to prioritize and follow through on multiple projects in a timely way
-Comfortable conducting home visits and commuting within the service area
-Have appropriate analytical skills to independently problem solve and make decisions
Type of Shift:
Monday-Friday, 40 hours a week.
Benefits:
401(k)
Health, Dental and Vision insurance
Employee assistance program
AFLAC
Paid time off
