Full-Time: 40 Hours Per Week
1st Shift: 8am - 4:30pm
Monday - Friday - Onsite
Location: Austintown Primary Care
Summary:
The SW Care Manager Plus, under the direction of the department Supervisor, applies graduate-level clinical social work skills for organizing patient care activities between participants (including patients and/or families) involved in a patient's care. The role facilitates the appropriate delivery of healthcare services, coordinates care with a multidisciplinary team within and across healthcare settings, and develops action plans to address gaps in care.
Responsibilities:
- Assessment: Systematically collects comprehensive and focused data relating to health needs and concerns of a patient, group, or population as they move across the care continuum.
- Outcomes Identification: Analyzes assessment data to determine patient/family/caregiver needs and facilitates appropriate services needed across the care continuum. Identifies expected outcomes specific to the patient, group, or population.
- Planning: Develops a patient- and/or population-centered plan of care that advocates strategies and alternatives to attain expected outcomes, considering funding resources, services, clinical standards, and outcomes. Provides consultation to influence plans of care, enhance professional capabilities, and seeks supervision when appropriate.
- Implementation: Implements the identified care plan to achieve expected outcomes. Employs educational strategies for patients, families, caregivers, and healthcare team members about treatment options, community resources, insurance benefits, and psychosocial concerns to support timely decisions. Maintains objectivity and adheres to timelines and standard work instructions.
- Evaluation: Monitors and communicates the status and progress of patients, groups, or populations toward expected outcomes across relevant professionals.
- Demonstrates understanding of care management, complex disease management, transitions of care, post-acute care options, and community management standards. Provides comprehensive care addressing physical, psychological, social, educational, and safety needs of patients of all ages.
- Performs other duties as required.
Other Information:
Technical Expertise
- Experience with healthcare coordination in managed care, homecare, or community agencies is preferred.
- Requires critical and analytical reasoning, clinical judgment, strong communication (verbal and written), interpersonal, organizational, and leadership skills.
- Demonstrates professional, effective, tactful communication skills, including written, verbal, and non-verbal.
- Proficiency in MS Office (Outlook, Excel, Word) required; Epic or similar EMR software preferred.
Education and Experience:
- Master's Degree in Social Work from an accredited program with a current unrestricted Ohio Social Work license (LSW) required.
- Minimum of 3 years of clinical healthcare experience required; pediatric ambulatory, care management, or health plan experience preferred.
- Certification by a recognized care management organization is preferred.
- No supervisory experience required.