Care Manager

Northwell•New York, NY

20h

About The Position

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. This role involves working with the treatment team to coordinate mental health, medical, and social service needs for a population requiring a high level of assistance to succeed in the community. Key tasks include creating and updating personalized care plans, collaborating with patients' families and social supports, suggesting alternative treatment plans when requests don't meet medical necessity, and instructing patients on procedures, healthcare provider instructions, and referrals. The Care Manager also links patients to social services programs like transportation and translation, conducts regular follow-ups to evaluate progress and ensure continuity of care, and maintains records of case management activities.

Requirements

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.

Responsibilities

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.