Care Manager (PER DIEM)
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 assistance to succeed in the community. The role creates and updates personalized care plans and works with patients, families, friends, social supports, and interdisciplinary treatment teams. The Care Manager assesses and coordinates medical, behavioral, rehabilitative, long-term care, and social service needs; connects clients with services and supports; educates patients; and conducts outreach and follow-ups to promote continuity of care and improved health outcomes. The position supports high-risk and high-need patients with complex health and social needs, working alongside primary care providers and across multiple providers and care settings. It also maintains confidential records and required statistical data, and performs related duties as required.
Requirements
- Master's degree or an equivalent combination of education and related experience.
- Current New York State license to practice as a Master's 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 needed to support care plans and treatment goals, including medical and behavioral health care, patient education, self-help recovery, and self-management.
- Conduct case reviews with the interdisciplinary team to monitor and evaluate client status and service needs.
- Maintain confidential departmental, hospital, and State forms, reports, and records in accordance with required standards.
- Comply with recordkeeping requirements, maintain statistical data regarding clients served and services rendered, and submit it according to program requirements.
- Develop, review, and revise individual plans of care with patients and family members to reflect patient preferences, education, and support for self-management.
- Conduct client outreach and engagement to assess 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 patients and coordinate care for high-risk and high-need patients with complex healthcare and social needs.
- Anticipate and coordinate services across multiple providers and care settings in collaboration with primary care providers.
- Provide self-management and health education for targeted populations with chronic disease conditions or high-cost specialty care.
- Ensure member goals are achieved within a specified time period based on individual needs, reasonable expectations, and documented outcomes.
- Suggest alternative treatment plans when requested services do not meet medical necessity criteria.
- Instruct and educate patients on 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 and promote continuity of care.
- Maintain records of case management activities.
- Perform related duties as required.
