Care Manager SDOH (Licensed)
Job Description
Position Purpose:
Under the direction of Manager, Social Determinants of Health (SDOH), the Care Manager, (CM) is a trusted member of the Care Management team who facilities the care of high-risk patients faced with social determinants, to promote adherence to key components of their health care. The SDOH/Flex CM engages patients, creates a trusting relationship, and provides care coordination and management to patients with SDOH, who have high rates of emergency department and inpatient utilization and/or significant SDOH-related vulnerability. They will work with the patient to set health goals and closely communicate with members of the patient’s care team. The CM provides support and assists members in understanding the implications and complexities of their current situation and/or overall personal care.
Key Responsibilities:
- Provides face-to-face or telephonic care coordination and care management to patients with social determinant challenges who have high rates of Emergency Department and/or Inpatient utilization and/or severe psychosocial vulnerability
- Provides care coordination and care management services to patients in the community, homes and health care settings that patients access
- Conducts comprehensive assessment with patients and performs clinical intervention through the development of a care management treatment plan specific to each member with high level acuity needs
- Assesses, plans, implements, monitors, and evaluates options and services to meet complex psychosocial health needs of patients
- Addresses barriers to follow through on health care including, but not limited to: homelessness/housing instability, financial resources, transportation, etc. and places referrals to community based resources as necessary
- Places external behavioral health community-based resources to assist patients in accessing quality and cost-effective care (i.e. - outpatient therapy, medication management, day treatment, Child Behavioral Health Initiative (CBHI) Services, etc.)
- Review benefits options, research community resources, and enables patients to be active participants in their own healthcare
- Coordinates care with internal and external resources to meet identified needs of patients’ care plan and collaborates with providers
- Monitors and evaluates effectiveness of care plan and modifies plan as needed
- Ensures patients are engaging with their PCP to complete their care management treatment plan or preventive care services
- Acts as a liaison and advocate between patient, family, physician, and facilities/agencies
- Interacts continuously with patients, family, physician(s), and other resources to determine appropriate action needed to address needs
- Provides clinical consultation to physicians, professional staff, and other teams’ members/supervisors to provide optimal quality patient care and effective operations
- Provides concise and thorough documentation through psycho/social assessment and progress notes, including changes in medical psycho/social functioning, progression and attainment of goals, referrals to internal and external agencies, and contact/involvement with patient’s family
- Demonstrates cultural sensitivity and respect for patients
Education:
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Years of Experience:
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Application Instructions
Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!
Apply OnlinePosted: 5/24/2023
Job Status: Full Time
Job Reference #: 130700