Care Manager BSW

Visiting Nurse Health System (Visiting Nurse) is hiring for a dynamic Care Coordinator with a high EQ to serve our members in Cobb & Fulton Counties. We seek a Social Worker (BSW) who provides case management activities to meet the needs of clients assigned to the consolidated care team. This role involves developing individualized care management plans, implementing the care plan through brokering and coordinating services, and monitoring and evaluating clinical outcomes to ensure professional, comprehensive, and cost-effective service delivery.

Serving the Atlanta area for over 78 years, Visiting Nurse is a leading provider of home healthcare, long-term care at home, hospice, and palliative care services. Our vision is to be the first choice for patients, families, payers, and healthcare providers when home healthcare services are needed, achieving top-tier patient and employee satisfaction scores and clinical outcomes.

Responsibilities

• Coordination of Services:
  • Arranges both CCSP and non-CCSP community-based services in collaboration with the RN care coordinator, the client, and family members.
  • Coordinates the Medicaid application team to ensure CCSP accessibility for functionally impaired Medicaid-eligible individuals.
  • Arranges emergency services as applicable.
  • Coordinates with the lead agency or DHR to ensure all CCSP components meet client needs.
  • Serves as the transition point and link between the assessment process and the effective delivery of direct services.
• Assessment and Care Plan:
  • Develops appropriate care plans in consultation with the client, client’s family, and service providers.
  • Implements the care plan and brokers CCSP services.
  • Completes assessments within 5 days of referral.
  • Follows up on direct services ordered within 10 days.
  • Reviews care plans within the first 60 days of LOC date and every 4 months at a minimum, or more often as needed.
  • Provides updated data monthly for reporting requirements.
  • Completes a reassessment annually or refers to team RN for reassessment to avoid lapse of MD orders.
• Documentation:
  • Documents all care management activity and service-related information.
  • Ensures documentation aligns with departmental cognitive standards (e.g., progress notes reflect care plans).
  • Maintains confidential case records on all CCSP clients.
  • Follows through on tasks assigned by the management team and requests from patients, families, referral sources, and the community.
  • Documents appropriate follow-up on client needs, whether related to CCSP services or other community resources.
• Financial:
  • Limits service amount and frequency to ensure costs do not exceed limitations established by the Division of Aging Services and the Department of Community Health.
  • Authorizes payment for service providers within DHR standards of promptness following the service date.
• Regulatory:
  • Requests redetermination of the client’s level of care prior to expiration.
  • Demonstrates knowledge and understanding of the CCSP manual, Medicare and Medicaid regulations, physicians’ orders, and standards of care.
  • Adheres to the policies and procedures of Visiting Nurse Health System.
• General Duties:
  • Maintains current knowledge of community resources to ensure realistic care plans and coordinate services.
  • Monitors service delivery to individual clients and follows up to ensure services are provided appropriately and meet client needs.
  • Stays updated on service standards for each CCSP service.
  • Actively participates in interdisciplinary conferences to coordinate care, problem-solve, and exchange information.
  • Documents case conference activities and follow-up.

Requirements

• Bachelor’s degree in Social Work, Sociology, Psychology, or a related field.
• Two years of experience in case management in a healthcare field.
• Two years of experience with Medicare, Medicaid, and other funding sources.
• Reliable transportation, including a valid driver’s license and proof of vehicle insurance.

Benefits

• Medical, Dental, and Vision insurance
• Employee Assistance Program
• Employee Discount
• Flexible Schedule
• Flexible Spending Account (FSA)
• Health Savings Account (HSA)
• Life insurance
• Paid Time Off (PTO) and 9 Holidays
• 403b with company match

Schedule

• Full-time
• Monday–Friday

Pay

$40,000 – $60,000 per year