Complex Case Manager (Social Services) - ACO

Essen Medical Associates • Bronx, NY

2d • Hybrid

About The Position

The Complex Case Manager (CCM) works in collaboration with the primary care provider and all other members of the care team to support our highest needs, most vulnerable patients, who are frequently in and out of institutional care. Part Patient Advocate, part case worker, part educator, the CCM is responsible for direct and indirect patient care, identifying clinical and health-related social needs and connects patients with relevant community resources.

Requirements

• Bachelors in Social Work, or similar
• 2+ years of experience in health care, and/or health-related social work
• A strong customer-service orientation, and extremely good verbal communication skills.
• The ability to work independently and exercise judgment in interactions with providers, patients, and their families/caregivers
• Ability to function in a fast-paced environment, to be held accountable for high performance standards, and to hold others accountable for high performance
• Good understanding of health care and health insurance concepts: Medicare, Medicaid, Long Term Care, home health, behavioral health, Advanced directives and hospice care, etc.
• Personality traits: curiosity, empathy, persistence

Nice To Haves

• Fluency in additional language(s), especially Spanish
• Certified Medicaid Assistor, or interest in gaining the certification
• Intermediate excel skills
• Some experience with electronic health records

Responsibilities

• Develop rapport with patients and family, conducting frequent check-ins and winning the patient’s trust in order to become their first call with all things related to their health.
• Occasionally visit patients in their homes to conduct safety assessments, patient education, and address social needs.
• Perform root-cause analysis of patient’s hospitalizations.
• Help the clinical team to understand where balls are dropped. What are the social, behavioral, and family dynamics at play that caused warning signs to be missed so that we couldn’t intervene in time, and how might we work with that patient and their support system to do better next time?
• Educate about, refer to, and help patients apply to community resources, city and state programs.
• Assist with and facilitate the transition of care from inpatient settings such as hospital, rehabilitation facilities and skilled nursing facilities to home.
• Address medication adherence and other treatment adherence.
• Communicate changes in patient’s status timely with the care team.
• Work with the Administrative staff to provide feedback that can assist in identifying and improving day-to-day operational processes.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level