Job Description
Responsible for providing a variety of direct and indirect social services to designated clients and families that facilitate their integration into the community to the fullest possible extent. Works with the treatment team and coordinate mental health, medical and social service needs with a population who is in need of a high level of assistance to be successful in the community. Creating and updating personalized care plans for patients.
Collaborating with patients' families, friends and social supports in developing treatment plans.
Suggesting alternative treatment plans when patients' services requests do not meet medical necessity criteria.
Instructing and educating patients on procedures, healthcare provider instructions and referrals.
Linking patients to social services programs and entitlements such as transportation assistance and translation services.
Conducting regular follow-ups with patients to evaluate progress, promote continuity of care and ensure improved health outcomes.
Maintaining records of case management activities.
Job Responsibility
- Provides comprehensive care management, care coordination and health promotion.
- Completes a comprehensive health assessment/reassessment inclusive of medical/behavioral/rehabilitative and long term care and social service needs.
- Links/refers client to needed services to support care plan/treatment goals, including medical/behavioral health care; patient education; self-help recovery and self-management.
- Conducts case reviews with interdisciplinary team to monitor/evaluate client status/service needs.
- Maintains, in a confidential manner all departmental, hospital and State forms, reports and records per required standards.
- Complies with all recordkeeping requirements and maintains statistical data regarding clients served and services rendered and submits these per program requirements.
- Develops, reviews, and revises the individual’s plan of care with patient /family members to ensure that the plan reflects individual’s preferences, education and support for self-management.
- Conducts client outreach and engagement activities to assess on-going emerging needs and to promote continuity of care and improved health outcomes.
- Consults with multidisciplinary team on client’s care plan/needs/goals; monitor/support/accompany the client to scheduled medical appointments. Involved in efforts to engage patients and coordinating care for high risk and high need patients with complex health care and social needs. Working alongside the primary care provider, proactively anticipates and coordinates care services across multiple providers and care settings and provides comprehensive self-management and health education for targeted member populations with chronic disease conditions or high cost specialty care. Demonstrates knowledge of complex care management core competencies, disease prognosis and outcomes, and is responsible for ensuring member goals are achieved within a specified time period based upon individual needs, reasonable expectations and well-documented outcomes.
- Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here, but considered related are not essential functions.
Job Qualification
- Master's Degree required, or equivalent combination of education and related experience.
- Current License to practice as a Masters Social Worker, or Current License to practice as a Clinical Social Worker in New York State required, plus specialized certifications as needed.
- 1-3 years of relevant experience, required.