Population Health Social Worker & Care Manager

CommunityCare HMO Inc.; Tulsa (OK); On-site; USD 60,000 - 85,000; Full time

Job summary

CommunityCare HMO Inc. in Tulsa, OK is seeking a qualified care management professional to assess member needs, coordinate care, and facilitate referrals for behavioral health services.

You will monitor outcomes and support provider performance to improve quality and continuity of care. Responsibilities include developing person-centered care plans with members and families, addressing social determinants of health, connecting to community resources, and guiding transitions of care after

Qualifications

• Master's degree in a mental health field and licensure in Oklahoma.
• Minimum four years of clinical experience in mental health.
• Experience with care management or population health is a plus.
• Managed behavioral health experience preferred.

Responsibilities

• Conduct comprehensive psychosocial assessments to identify member needs, barriers to care, health-related social needs, and social determinants of health.
• Develop individualized, person-centered care plans in collaboration with members, caregivers, providers, and the interdisciplinary care team.
• Establish measurable goals and interventions that support improved health outcomes, member engagement, and appropriate utilization of services.
• Connect members to community-based organizations, public assistance programs, behavioral health services, long-term services and supports, and other appropriate resources.
• Collaborate with physicians, nurses, behavioral health specialists, pharmacists, case managers, utilization management staff, and community partners.
• Support transitions of care by assisting members after hospitalizations, emergency department visits, skilled nursing facility stays, or other care transitions.
• Assist members in navigating benefits, covered services, community support, and healthcare systems.
• Participate in population health initiatives designed to improve preventive care, chronic condition management, health equity, and quality outcomes.
• Document assessments, interventions, care plans, member contacts, referrals, outcomes, and case closure activities accurately and timely in designated systems.
• Maintain compliance with CMS requirements, URAC accreditation standards, HIPAA, privacy and security regulations, and company policies.
• Monitor progress toward member goals and update care plans as needed.
• Identify trends, barriers, and opportunities to improve population health outcomes and member experience.

Skills

Mental health assessment

Problem solving

Communication with providers

Social determinants of health

English fluency

Microsoft Office

Education

Master's Degree in a mental health field

Active, unrestricted license to practice as a social worker in Oklahoma

Active, unrestricted license to practice as a mental health professional in Oklahoma

Four years of related clinical experience in mental health

Tools

Microsoft Office

Job description

CommunityCare HMO Inc. in Tulsa, OK is seeking a qualified care management professional to assess member needs, coordinate care, and facilitate referrals for behavioral health services.

You will monitor outcomes and support provider performance to improve quality and continuity of care. Responsibilities include developing person-centered care plans with members and families, addressing social determinants of health, connecting to community resources, and guiding transitions of care after