Social Worker

Job Title: Social Worker
Department: CIN Care Management
Date Created/Revised: 5-1-23
Reporting to: Director of Care Management

HYBRID/REMOTE

Position Summary:

Accountable for engaging with patients and their family in telephonic-based Care Management. This role will provide care management to different targeted populations in various program arrangements, including but not limited to, management of care transitions, longitudinal care management and disease based care management. Coordinates with Skilled Nursing Facilities and other post acute providers. Works under direct supervision and is a part of an interdisciplinary Care Management team. Responsible for managing the coordination of behavioral health services and addressing the social determinants of the targeted population. Responsible for end-to-end comprehensive care management, overall care planning and performance metrics for assigned caseload.

General Functions:

• Engages with patients and their family, and members of the health care delivery team about goals of care and the care plan; knowledgeable about level of care needs, community resources, and insurance benefits, so that appropriate referrals and resource linkages can be made to support ongoing self-care needs.

• Liases with members of the Stony Brook Post Acute Care Collaboration (PACC) around progression of care for assigned patients
• Evaluate social functioning particularly as it relates to medical problems. Provide support to individuals and their families when personal, social, and/or environmental difficulties exist.
• Facilitates end of life care planning; advance care planning education, documentation, and assistance with the completion of advance directive to physicians, including medical power of attorney and out of hospital do not resuscitate. Provide individual and family support for adjustment issues, grief, and end of life issues.
• Assess financial security with consideration of diagnosis, prognosis and medical necessities. Facilitate and manage referral to agencies for financial assistance if indicated.
• Educate on chronic disease self-management, including instruction on coping strategies, planning, goal setting, behavior modeling, problem-solving techniques, and decision making related to managing chronic conditions.
• Demonstrates an understanding of care management, complex disease management, transitions of care, post-acute care landscape/options, and community management standards. Maintain familiarity with community resources and agencies for assigned locality and update resources as necessary.

• Demonstrates an understanding of current climate of economics and funding resources for care delivery/care management. Utilizes resources efficiently and effectively.
• Demonstrates an understanding of managed care trends, payer regulations, reimbursement, and the effect of utilization on the different methods of reimbursement.

• Participates in interdisciplinary “team rounds” to address utilization/resources and progression of care issues. Assist the care team members understanding the significant social and emotional factors related to the individual's medical needs. Assist in interdisciplinary team meetings with the objective of meeting the psycho-social needs of individuals to enable them to utilize medical, mental health, and community services appropriately. Assists in developing and implementing an improvement plan to address issues.

• Adheres to communicated care management productivity metrics, and maintenance of caseload as per policy. Adheres to quality standards, including adherence to model of care/standard operating procedures as well as comprehensive documentation, actionable care plans, and appropriate cases closed in a timely fashion.

• Develops strong working relationships with internal and external customers to provide exemplary service and achieve goals. Maintain professional relationships with other agencies and acts as an affiliate with community agencies

• Proficiency in various word processing, spreadsheet, graphics, and database programs, including Microsoft Word, Excel, PowerPoint, Outlook, etc.
• Demonstrates the ability to evaluate utilization/resource/clinical care management data to identify trends, develop action plans, and program modification for improved outcomes.
• Participates in special projects or other duties as assigned.

Position Qualifications:

• Minimum Education:
  • Master’s in Social Work or Master’s Licensed Health Care Professional

• Minimum Experience:
  • 5 years of clinical experience in a direct patient care setting.
  • 2 years of case management experience in an acute, community, or post-acute provider or health plan.
  • Working knowledge of the continuum of care [options for different levels of care], with solid understanding of the principles of Value Base Care, Population Health Strategies and Utilization Management.
  • Working knowledge of customer service principles and standards
  • Working knowledge of computers and basic software applications used in job functions, such as word processing, databases, spreadsheets, and others as needed.
  • Working knowledge and ability to apply professional standards of practice in a work environment.
• Required Certifications/Licensure:
  • Possession of a current licensed master social worker (LMSW) in the state of hire
• Preferred Certifications/Licensure:
  • Certified Case Manager (CCM) or accredited equivalent certification.