Social Work Care Manager II

Responsible for partnering with members of the health care team to assess needs, coordinate services, and implement care plans that support safe, effective, and cost-conscious care delivery. Connects members with appropriate clinical, behavioral health, and community resources; monitors progress toward care goals; and assists with care transitions and discharge planning.  Supports members in maximizing independence, addressing psychosocial needs, and improving overall health and quality of life.

• In close collaboration with the member/members family, and members of the health care team, assesses the members health status, functional limitations, psychological status, social support systems, resources, environmental factors, and response to treatment.
• Uses motivational interviewing techniques to identify members readiness for change, creates appropriate care plan based on assessments, assists member with health system navigation and connection to community resources.
• Provides supportive counseling and education to members, families and caregivers, members of the health care team, and others including end-of-life issues and Advance Directives.
• Effectively manages and coordinates assigned caseload consistent with established criteria. Ensures consistent and reliable documentation of case management activities in compliance with all organization and department standards.
• Facilitates application process for accessing local, state, and federally funded programs (e.g., Medicaid, Medicare, Disability) and/or refers to appropriate community resources.
• Coordinates care across the care continuum for members receiving behavioral health and substance abuse services.
• Responsibilities include, but are not limited to, problem identification, psychosocial assessment, financial counseling/referral, accessing community resources, placement for care, guiding the member through health-related legal processes, or consultation and support to other health care professionals.

• Minimum two (2) years of experience in case management OR three (3) years of clinical experience are required.

• Masters degree in social work (MSW) required.

• Basic Life Support within 3 months of hire

• Exceptional oral and written communication skills to interact with diverse members and providers and present care plan.
• Exceptional listening skills to assess needs and identify problems.
• Cultural humility to appreciate unique perspectives, backgrounds, and differences.

• Two (2) years experience in a community-based setting with knowledge of community agency resources.
• Community membership/shared experience with community being served.
• Proficient computer skills with Epic and Microsoft Office suite (Outlook, Teams, Excel and Word).