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Frederick Health Care Manager Social Worker assists in coordinating care across Frederick Health Medical Group practices and CIN networks, evaluating social determinants, and guiding patients and families through the health system with planning and referrals.
You will work with clinicians to optimize transitions of care, perform psychosocial assessments, and support self-management strategies in both hospital and ambulatory settings, while aligning with FH standards and regulatory requirements.
Supports, and is responsible for incorporating into job performance, the Frederick Health (FH) mission, vision, core values and customer service philosophy and adheres to the FH Compliance Program, including following all regulatory requirements and the FH Standards of Behavior. The Care Manager Social Worker works collaboratively with medical providers and healthcare professionals within Frederick Health and across the healthcare continuum. Professional social work skills are utilized to assess for unmet social needs, provide information and referrals to appropriate resources, psychosocial assessment, counseling support, and establishing plans for management of identified needs in the acute and/or ambulatory setting. Assessment, planning, interventions, and reassessment are performed within a collaborative and interdisciplinary team. The Care Manager Social Worker will also assist with patient/family navigation through the healthcare continuum, while focusing on improving quality outcomes and ensuring appropriate utilization of resources through effective care management practices.
Light Work
Bloodborne Pathogens Exposure Risk: Category B – MAY have exposure to blood or body fluids.
Reports to Department Manager
The Integrated Care Management- Care Manager Social Worker will work collaboratively with physicians, staff, and other healthcare professionals within ambulatory Frederick Health Medical Group practices and/or community practices that participate in the clinically integrated network (CIN)- Frederick Integrated Healthcare Network (FIHN). Care coordination will focus on requirements of various value-based care contracts and population health focus areas. Transitions of care, risk stratification data, and provider/care team referrals will initiate care management within this population. The Care Manager Social Worker will interpret data to evaluate and implement care management strategies and interventions related to attributed beneficiaries and patient populations. Optimizes patient wellness through the promotion of self-management strategies. Telephonic, medical office, and home visits will be conducted.
The Transitional and Chronic Care Management (TCCM) Social Worker will work collaboratively with the TCCM clinicians, community programs and Frederick Health Hospital case managers. Social worker will focus on patient needs to ensure a healthy environment in their home and to be able to age in place as the goal. Optimize patient wellness through the promotion of self-management strategies. Work with FHH case managers on patients with contracts who DC to the community to ensure timely follow-up and make plans for when contract ends. Telephonic and home visits will be conducted.
Behavioral Health Social Worker will concentrate on managing patients needing assistance with mental health and substance abuse issues to ensure optimal outcomes for the patients in the community.
The Comprehensive Care Center (CCC) Care Manager works collaboratively with practice providers, staff, and other healthcare professionals to provide care coordination across the healthcare continuum. The social worker will assist the patient and their family in identifying barriers to medical care and helping to implement solutions and is responsible for connecting patients to required medical services and community resources. The social worker assists CCC patients in navigating the healthcare continuum while improving the coordination of care focused on enhancing quality outcomes while ensuring appropriate utilization of resources through effective care management practices. CCC SW will proactively identify opportunities to improve the patient and family experience of care and improve the efficiency and effectiveness of resource use.
Frederick Health offers a comprehensive and affordable benefits package. Health, Dental and Vision insurance are offered the 1st of the month after 30 days of employment to all employees hired to work at least 20 hours per week and we offer multiple plans to best meet your and your family's needs. Life insurance, Short-Term Income Replacement and Long-Term Disability are employer paid for eligible employees. Frederick Health offers a robust Paid Time Off program for eligible employees. Our 403B retirement plan helps you save for your retirement and includes an employer match to eligible employees. All employees have access to free financial planning sessions. We also offer an educational assistance program to support your education goals as well as an employer paid Employee Assistance Program. Pay is based on experience, skills and education. If position is part-time, salary will be pro-rated based on scheduled hours. The pay range may also vary within the stated range based on specialty if applicable. Non-Exempt positions may have shift differential and/or Overtime paid, if applicable.
Hourly range: $33.67 - $49.78