What are the responsibilities and job description for the Community Care Team HOME Care Manager Social Worker position at Andwell Health Partners?
Job Description
Job Description
Title : Community Care Team HOME Care Manager Social Worker
Territory : Mid coast / Southern Maine & Martins Point Health Care
What You’ll Do :
- Care Manager Social Worker will, in collaboration with the primary care practice, coordinate services using a systematic and cost-effective approach to provide patient-centered care for a defined population.
- The Care Manager will engage the patient to reduce unnecessary health care services and improve their overall health and well-being. A specialized focus on housing support will be provided to HOME enrolled patients.
- Care Manager to work with each practice to assess the gaps in care coordination as well as patients’ access to and utilization of community supports.
- The Care manager will need to collaborate with designated physician practices and community partners to determine the best model for addressing the needs of the most complex patients.
- Work with patients with complex emotional-social issues and mental health concerns.
- Work with CCT, primary care provider, and Mainecare to identify recipients who are most likely to benefit from care management intervention and agree to participate.
- Care manager may make patient visits prior to hospital discharge, in the primary care practice, in the home or public setting.
What You’ll Bring :
