Care Manager, SDOH

Position Purpose:

Under the direction of Manager, Social Determinants of Health (SDOH), the Care Manager, (SDOH – CM) is a trusted member of the Care Management team who facilities the care of high-risk patients faced with social determinant and behavioral health challenges to promote adherence to key components of their health care. The SDOH CM engages patients, creates a trusting relationship, and provides care coordination and management to patients with SDOH challenges who have high rates of emergency department and inpatient utilization and/or significant financial vulnerability. The SDOH - 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 and or telephonic care coordination and care management to patients with social determinant and behavioral health 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, and health care settings that patients access
• Conducts comprehensive care needs assessments with patients, completing a care management treatment plan specific to each member.
• 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, childcare, etc. and places referrals to community-based resources as necessary
• Places external behavioral health and/or substance use community-based resources to assist patient in accessing quality and cost-effective care (i.e. - outpatient therapy, medication management, day treatment, Child Behavioral Health Initiative Services, etc.)
• Reviews benefits options, research community resources, trains/creates behavioral routines and enables patients to be active participants in their own healthcare
• Coordinates care with internal and external resources to meet identified needs of the patient's 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 the patient, family, physician, and facilities/agencies
• Interacts continuously with members, family, physician(s), and other resources to determine appropriate behavioral action needed to address medical needs
• 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 the patient