Social Care Manager-Capital Region

About the role

The Social Care Manager is the direct point of contact for Members with ongoing HRSNs and is responsible for conducting eligibility assessments for Managed Medicaid Members eligible for enhanced HRSN services, as well as development of Social Care Plans.

Responsibilities

• Manage incoming referrals for enhanced HRSN care management to support successful and timely connections for community members.
• Provide longitudinal care management for Members receiving one or more enhanced HRSN services.
• Utilize the Electronic Provider Assisted Claim Entry System/Medicaid Eligibility Verification System (ePACES/MEVS) and other data sources to confirm Medicaid enrollment and HRSN screening status, as well as existing care team management.
• Conduct and document outreach to community members in alignment with required frequency, modality, and timeframe.
• Manage Member consent and attestation as required throughout the screening, assessment, and care management process.
• Conduct HRSN screening using the Accountable Health Communities (AHC) screening tool to assess Member HRSNs.
• Conduct eligibility assessments to determine Member eligibility for enhanced HRSN services and refer Members to eligible programs and services to include enhanced HRSN services and/or existing federal, state, and local resources.
• Develop Social Care Plans that include a summary of Member needs, eligibility, and services to which they are referred.
• Ensure referrals are acted upon by HRSN service providers within required timeframes and redirect referrals as necessary to support service connection. Document progress notes and action taken with each referral, as detailed in the Network Standards and Quality Program.
• Update the Social Care Plan throughout service provision in collaboration with the Member and service provider to reflect strategies and interventions for meeting identified HRSNs.
• Maintain effective communication with internal team members, community members, and partner organizations to ensure overall coordination of care.
• Collaborate with Performance team to report partner effectiveness and efficiency regarding referral response and service delivery and escalate community member service issues in a timely manner.
• Regularly use data and data tools to report referral patterns and trends to the Referral Coordination Manager.
• Share detailed feedback on successes and challenges of the role with the Referral Coordination Manager and continually look for opportunities to enhance and simplify the community member experience.
• Effectively work in a hybrid work environment. Some local travel may be required for meetings, community events, and other job-related responsibilities.
• Demonstrate commitment to the values of diversity, equity, and inclusion.
• Maintain current knowledge and understanding of Medicaid and local transformation, including New York Health Equity Reform (NYHER) 1115 Wavier Amendment, Waiver programs, Triple Aim, and value-based purchasing (VBP).

Requirements

• Minimum of 5+ years related experience in a clinical, non-profit, or managed-care organization environment preferred.
• Extensive knowledge and understanding of health equity, social drivers of health, and social care data.
• Excellent communication and presentation skills.
• Experience using translation services preferred.
• Ability to build collaborative working relationships with others inside and outside the organization through cooperation, mutual respect and capacity to inspire and motivate others.
• Thriving working with multiple systems and processes.
• Extremely detailed-oriented and capable of multitasking.
• Proven record of hitting key metrics, defining effective data-driven network development strategies, and problem-solving.
• Proficient computer skills and willingness to learn additional software applications.
• Demonstrated ability to thrive in a demanding environment.

Qualifications

• Associate degree in health, social services, or related field preferred. Equivalent work experience in a related field may be considered in lieu of degree requirements.

Skills

• Extensive knowledge and understanding of health equity, social drivers of health, and social care data.
• Excellent communication and presentation skills.
• Experience using translation services preferred.
• Ability to build collaborative working relationships with others inside and outside the organization through cooperation, mutual respect and capacity to inspire and motivate others.
• Thriving working with multiple systems and processes.
• Extremely detailed-oriented and capable of multitasking.
• Proven record of hitting key metrics, defining effective data-driven network development strategies, and problem-solving.
• Proficient computer skills and willingness to learn additional software applications.
• Demonstrated ability to thrive in a demanding environment.