Remote SNP Social Worker — Care Management

WVU Medicine; Maryland; Hybrid; USD 70,000 - 95,000; Full time

Job summary

PHH Peak Health Holdings is seeking a SNP Social Worker to support MA/Medicaid members through care management, assessments, and coordinated service plans. The role emphasizes psychosocial, environmental, and economic factors, with telephonic assessments and cross-team collaboration to improve member health outcomes.

The position requires a Master's in Social Work and state licensure (WV/PA/OH/MD) with at least two years of clinical experience; LICSW is preferred.

Qualifications

• Masters Degree in Social Work or related field.
• Current social worker licensure for the applicable service area: WV/LCSW/LISW/LISW-C (WV); PA: LSW or LCSW; OH: LSW/LISW/LISW-S; MD: LMSW/LCSW/LISW-C.

Responsibilities

• Participate in activities related to care management program build, implementation, oversight, and delegation.
• Assist in ensuring CMS SNP Model of Care (MOC) expectations, NCQA standards, and Medicare Advantage regulatory requirements.
• Perform psychological, social and economic care management interventions for members with severe/persistent mental or emotional disorders.
• Perform telephonic behavioral health comprehensive assessments of environmental, behavioral, psychological, economic and social factors.
• Develop individualized and culturally sensitive care plans in collaboration with the member’s assigned CM.
• Conduct telephonic re-assessments, care plan revisions and evaluate effectiveness of the care plan.
• Collaborate with ICT for SDOH and BH needs; participate in ICT meetings.
• Recognize early signs of decompensation and prompt case management intervention.
• Serve as an additional contact during transitions of care.
• Co-manage cases with CM addressing psycho-social, economic and cultural issues.
• Serve as primary socio-economic resource for D-SNP Care Management Team.
• Document in the member’s case accurately and timely for care coordination.
• Adhere to CMS, CFR, local/state/national regulatory guidelines along with MOC.
• Collaborate with interdisciplinary care team to access community resources.
• Screen, diagnose, treat, and manage mental health/substance abuse problems.
• Knowledge of hospital resources to access patient care needs.
• Maintain knowledge of community resources; liaison with healthcare system.
• Coordinate financial assistance and entitlement/referrals.

Job description

PHH Peak Health Holdings is seeking a SNP Social Worker to support MA/Medicaid members through care management, assessments, and coordinated service plans. The role emphasizes psychosocial, environmental, and economic factors, with telephonic assessments and cross-team collaboration to improve member health outcomes.

The position requires a Master's in Social Work and state licensure (WV/PA/OH/MD) with at least two years of clinical experience; LICSW is preferred.