CARE MANAGER-SW /LISW Required

SUBFUNCTION DEFINITION: Therapists who diagnose and then treat individuals who have mental, behavioral, and emotional disorders.


REPRESENTATIVE RESPONSIBILITIES

• Psychosocial Assessment

Conduct a comprehensive psychosocial assessment of the patient's/family's health and psychosocial needs while exercising an intuitive understanding of complexity and uniqueness to identify strengths, challenges, and opportunities. Identify cases that meet criteria for need of care coordination through the comprehensive needs assessment. Stratifies patients to match client needs to the most cost effective model of care coordination. Exhibits advanced interviewing and therapeutic intervention skills with regard to abuse, neglect, and/or other safety risk factors. Report suspicions of abuse and neglect to legally mandated authorities for investigations. Completes documentation with accuracy and clarity.

• Resource Management

Partner with the patient/family/caregivers in obtaining financial assistance, community resources, and/or specialized equipment. Develops resource networks, excels at resource utilization, and acts as a resource to peers. Provide real time accurate information to patient/family/caregiver for resources for which they are eligible. Provide condition-specific and related medical, financial, educational, and social supportive resource information. Identifies needs, develops programs, and evaluates outcomes for special populations, as needed, and implements changes based on outcomes. Facilitates collaboration with community agencies to enhance investigation and intervention process. Advocates for patient population on a systems level (hospital, organization, and/or community) by developing programs and protocols to better meet the needs of the patient population. Educating patient and family to recognize progress and assist in identifying need for changes in treatment plan

• Psychosocial Intervention

Provide psychosocial services as identified in the patient's comprehensive plan of care. Creates opportunities for and provides supportive counseling with the goal of maximizing emotional coping and adherence to the treatment plan. Facilitates and enhances collaboration with the referral source and appropriate members of the health care team in a timely and effective manner. Use expert knowledge and skill to educate the patient/family/caregiver and members of the health care team about evidenced-based treatment options. an expert in providing self-management support to high risk/complex patients/families to increase their skills and confidence to effectively manage their chronic care conditions at home. Identifies needs, develops programs, and evaluates outcomes for special populations as needed, and implements changes based on outcomes. Motivates and empowers patients/families/caregiver through the use of anticipatory guidance and planning to reduce or eliminate psychosocial barriers to discharge. Is seen as a leader in initiating and facilitating family centered care team meetings. Demonstrates a therapeutic approach focusing on micro and macro systems including assessment and crisis intervention with the goal of problem prevention.

• Interdisciplinary Collaboration

Working for system improvement, promoting patient/family/caregiver well-being. Advocates for patient population on a system level (hospital, organization, and/or community) by developing programs and protocols to better meet the needs of the patient population. Is seen as a resource and initiates liaison role between the patient/family/caregiver within the medical team and outside agencies. An expert in mediating as needed within the medical team on behalf of the patient/family/caregiver. Empower the patient/family/caregiver to problem-solve by exploring options of care when available and alternative plans, when necessary, to achieve desired outcomes. Develops processes for effective and efficient communication and coordination between members of the health care team while involving the patient/family/caregiver in the decision making process in order to minimize fragmentation of services.

• Coordination

Facilitates communication and coordination between members of the health care team (including the medical home and community services), involving the patient/family in the decision-making process in order to minimize fragmentation in the services. Attends and leads care conferences. Insures that key components of the plan of care and/or patient needs are communicated to subsequent care providers and ensure safe handoffs. Ensures the health care team integrates multiple sources of health care information and communicates this summary, thereby building caregiver skills and fostering relationships between the health care team and families. Demonstrates an understanding of legal and regulatory issues (HIPPA, EMTALA, regulatory agencies, CMS, legal P&P) impacting the care delivery and reimbursement process. Negotiates and advocates for the patient for services and resources needed. Provides patient/family education regarding post-acute services, community resources or other as needs identified. Creates an environment to support patient safety by integrating patient safety goals into daily practice based of the patient's age and the population served.

EDUCATION/EXPERIENCE
Required:

• Bachelor degree in related field. May require clinical license, certification or training
• Master's degree in Social Work
• 5 - 7 years of work experience in a related job discipline.

Preferred:
Unique Skills: