Care Manager - License Master Social Work
About The Position
The Care Manager provides direct and indirect social services to designated clients and families, helping them integrate into the community and coordinating mental health, medical, and social-service needs for people who need substantial support to succeed in the community. The role creates and updates personalized care plans and works with patients, families, primary care providers, and multidisciplinary teams to coordinate services, support self-management, and promote continuity of care and improved health outcomes. The Care Manager assesses medical, behavioral, rehabilitative, long-term-care, and social-service needs; connects clients with appropriate services and entitlements; and follows up on progress and emerging needs. The role also maintains confidential records and required program data, monitors care-plan outcomes, and proposes alternative treatment plans when requested services do not meet medical-necessity criteria. Related duties may be assigned as required.
Requirements
- Master’s degree, or an equivalent combination of education and related experience.
- Current New York State license to practice as a Masters Social Worker or Clinical Social Worker.
- Specialized certifications as needed.
- 1–3 years of relevant experience.
Responsibilities
- Provide comprehensive care management, care coordination, and health promotion.
- Complete comprehensive health assessments and reassessments covering medical, behavioral, rehabilitative, long-term-care, and social-service needs.
- Link or refer clients to services that support care-plan and treatment goals, including medical and behavioral health care, patient education, recovery support, and self-management.
- Conduct case reviews with the interdisciplinary team to monitor and evaluate client status and service needs.
- Maintain departmental, hospital, and State forms, reports, and records confidentially and according to required standards.
- Comply with recordkeeping requirements, maintain statistical data on clients served and services rendered, and submit data according to program requirements.
- Develop, review, and revise individual care plans with patients and family members, reflecting patient preferences and providing education and support for self-management.
- Conduct outreach and engagement to assess ongoing and emerging needs and promote continuity of care and improved health outcomes.
- Consult with multidisciplinary teams about client care plans, needs, and goals; monitor, support, or accompany clients to scheduled medical appointments.
- Engage high-risk and high-need patients with complex health and social needs, proactively coordinate services across providers and care settings alongside primary care providers, and provide self-management and health education to targeted populations with chronic conditions or high-cost specialty care needs.
- Apply complex-care-management competencies and knowledge of disease prognosis and outcomes to support achievement of member goals within specified time periods and document outcomes.
- Collaborate with patients’ families, friends, and social supports in developing treatment plans.
- Suggest alternative treatment plans when requested services do not meet medical-necessity criteria.
- Instruct and educate patients about procedures, healthcare-provider instructions, and referrals.
- Connect patients with social-service programs and entitlements, including transportation assistance and translation services.
- Conduct regular patient follow-ups to evaluate progress, promote continuity of care, and improve health outcomes.
- Maintain records of case-management activities.
- Perform related duties as required.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
