Social Work Care Coordinator (bilingual Chinese speaking preferred)

VNS Health; New York (NY); On-site; USD 70,000 - 88,000; Full time

Job summary

VNS Health in New York is seeking a Social Worker to assess, plan and provide intensive care management across acute, home, and long-term care settings. You will develop comprehensive care plans with members, families and physicians, coordinate services, and monitor outcomes to ensure optimal, cost-effective care.

The role includes evaluating eligibility for program services, collaborating with interdisciplinary teams, and providing social work support in accordance with NASW ethics.

Qualifications

• Licenses and Certifications: Licensed Social Worker in NYS preferred.
• Education: Master's in Social Work; Case Management Certification preferred.
• Work Experience: Minimum of three years in Social Work.
• Two years in case management/community-based settings preferred.
• Bilingual skills may be required by operations.
• Clinical geriatrics, long-term care and managed care experience preferred.

Responsibilities

• Assess, plan and provide intensive care management across settings.
• Develop care plans with members, families and physicians.
• Coordinate long-term care services in home/community sites.
• Monitor and adjust plans based on member needs and outcomes.
• Collaborate with interdisciplinary teams and external providers.
• Ensure fiscally responsible use of services and appropriate care.

Skills

Social Work

Case Management

Geriatrics

Managed Care

Education

Master's Degree in Social Work

Case Management Certification

Job description

Overview

• Assesses, plans and provides intensive and continuous care management across acute, home, and long-term care settings. Develops and negotiates care plans with members, families and physicians.
• Assesses a person's living condition/situation, cultural influences, and functioning to identify the individual's needs; develops a comprehensive care plan that addresses those needs.
• Assesses an enrollee's eligibility for Program services based on his or her health, medical, financial, legal and psychosocial status, initially and on an ongoing basis.
• Plans specific objectives, goals and actions designed to meet the member's needs as identified in the assessment process that are action-oriented, time-specific and cost effective.
• Implements specific care management activities and or interventions that lead to accomplishing the goals set forth in the plan of care.
• Coordinates, facilitates and arranges for long term care services in the home and community-based sites, such as adult day care, nursing homes, rehab facilities, etc. Arranges for on-going nursing care, service authorization and periodic assessment.
• Collaborates and negotiates with interdisciplinary teams, health care providers, family members, and third party payors, as applicable, across all health settings to ensure optimum delivery and coordination of services to members.
• Monitors care management activities, services, and members' responses to interventions, to determine the effectiveness of the plan of care and the utilization of services.
• Evaluates the effectiveness of the plan of care in reaching desired outcomes and goals; makes modifications or changes in the plan of care as needed.
• Identifies trends and needs of groups in the community and plans interventions based on these identified needs.
• Provides care management services across sites and collaborates with appropriate facility discharge planner and/or HCC when members are transitioned between settings.
• Manages expenditures to ensure effective use of covered services within a capitated rate. Fiscally responsible in providing services based on members' needs.
• Provides social work services in accordance with NASW code of ethics, VNS Health policies, practices, and procedures.
• Participates in outreach activities to promote knowledge of the Program and its services and to coordinate Program activities with outside community agencies and health care providers (e.g., community health screening, In Services).
• Participates in the development of programs to meet the specialized needs of this selected patient population.
• Documents services in accordance with Health Plans Community Care standards and Managed Long Term Care (MLTC) and Licensed Home Care Services Agency (LHCSA) regulations.
• Participates in special projects and performs other duties as assigned.

For Palliative Care Only:

• Understands and supports ability to cope with patients' illness. Provides emotional, spiritual, and practical support for patient and family
• Reviews tools, programs and other resources for potential serious illness program appropriate patients and make referral as necessary.
• Provides education to patients and their families to better understand patients' disease and diagnosis.
• Facilitates open discussion about treatment choices for patient's illness (including difficult and complex choices) and management of symptoms.
• Provides expertise in treatment of pain and other symptoms.

Qualifications

Licenses and Certifications: License and current registration to practice as a Licensed Social Worker in New York State preferred

Education: Master's Degree in Social Work required Case Management Certification preferred

Work Experience: Minimum of three years of Social Work experience required.

Minimum of two years in a case management and/or community based environment preferred.

Bilingual skills may be required, as determined by operational needs.

Clinical expertise in geriatrics, Long Term care and Managed care experience preferred

Pay Range

USD $70,200.00 - USD $87,700.00 /Yr.

About Us

VNS Health has been committed to meeting the needs of New Yorkers for over 130 years. We're one of the largest nonprofit home- and community-based health care organizations in the country, and today, more than 11,500 team members work together to make a difference in the lives of more than 99,000 patients and members on any given day.