Care Manager SW (Medicare)

About the Role

The primary goal of the Care Manager is to optimize members’ health care and delivery of care experience with expected cost savings due to improved quality of care. This is accomplished through engagement and understanding of the member’s needs, environment, providers, support system, and optimization of services available to them. The Care Manager is expected to assess and evaluate members’ needs and be a creative, efficient, and resourceful problem solver. The role is monitored and assessed based on value added to improved health status of members, including disease management (physical and behavioral), medication adherence, and utilization of emergency services, hospitalizations, and avoidance of complications.

Responsibilities

• Physically meet members where they are to gain a deep understanding of their situation and needs.
• Problem-solve members’ issues across clinical, psychosocial, financial, environmental, and safety aspects.
• Provide services to members of varying ages, clinical scenarios, cultures, financial means, social support, and motivation levels.
• Engage members in a collaborative relationship, empowering them to manage their physical, psychosocial, and environmental health for lifelong well-being.
• Assess risks and gaps in care.
• Maximize members’ access to available resources.
• Prepare a member-oriented plan of care with the member, caregivers, and healthcare providers, integrating cultural sensitivity and privacy practices.
• Communicate the plan of care to the Primary Care Physician initially and provide updates at least monthly.
• Ensure member and caregiver understanding, addressing language barriers, stress reactions, or cognitive limitations using verbal and nonverbal techniques.
• Train members on relevant chronic diseases, preventive care, medication management (adherence), home safety, and other health-related topics.
• Provide complex care management, including ensuring access to care, reducing unnecessary hospitalizations, and appropriately referring to community supports.
• Advocate for members by assisting them in addressing challenges and making informed choices regarding clinical status and treatment options.
• Develop collaborative relationships with clinical providers and facility staff.
• Employ critical thinking and judgment when dealing with unplanned issues.
• Use data as a tool in tracking and trending outcomes and clinical information.
• Maintain accurate, comprehensive, and current clinical and non-clinical documentation.
• Comply with all orientation requirements, mandatory trainings, organizational and departmental policies, and procedures, and actively participate in the evaluation process.
• Maintain professional competencies as a Care Manager.
• Perform other duties as assigned by the Team Lead and Manager.

Requirements

• Master’s Degree required.
• Minimum 3 years’ prior experience in Case Management in a healthcare and/or Managed Care setting (strongly preferred).
• Proficiency with computers, navigating multiple systems, and web-based applications.
• Ability to proficiently read and interpret medical records, claims data, pharmacy and lab reports, and prescriptions.
• Ability to travel within the MetroPlusHealth service area for home visits, facility visits to clinical providers, and visits to community, faith, and other social service-based agencies.
• Ability to work closely with members and caregivers.

Qualifications

• A valid license and current registration to practice as a Licensed Master Social Worker (LMSW) or Licensed Clinical Social Worker (LCSW) issued by the New York State Education Department (NYSED).

Skills

• Integrity and trust.
• Customer focus.
• Strong functional/technical and written/oral communication skills.
• Confident, autonomous, solution-driven, detail-oriented, with high standards of excellence.
• Nonjudgmental, diplomatic, resourceful, intuitive, dedicated, resilient, and proactive.
• Strong verbal and written communication skills, including motivational coaching, influencing, and negotiation abilities.
• Time management and organizational skills.
• Strong problem-solving skills.
• Ability to prioritize and manage changing priorities under pressure.
• Proficiency in Microsoft Office applications (Word, Excel, PowerPoint, Outlook).
• Ability to form effective working relationships with a wide range of individuals.

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