Fortify Licensed Care Manager - Registered Nurse (RN)/ Licensed Clinical Social Worker (LCSW)

University of Virginia

1d•Hybrid

About The Position

Leverage clinical expertise in caring for Virginia’s most vulnerable children and their families. The Licensed Care Manager utilizes their skills and knowledge base to support the optimal health and wellness of the pediatric patient(s). Through telephonic outreach, the Licensed Care Manager communicates with patients’ families to complete assessments and develop individualized care plans that best support the medical and social needs of the patient and family. Individual contributors with responsibility in a professional discipline or specialty. Spends majority of time leading the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills normally acquired through advanced education (typically University). Provides care that is inclusive and respectful of socioeconomic status, race, ethnicity, age, mental or physical disability, religion, gender, sexual orientation, or national origin. Builds open, trusting, respectful relationships with diverse patients and families both remotely and in person. Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex health and social factors which impact optimal health. Anticipates and responds to patient and family needs. Problem-solves unique barriers to communication and care. Communicates effectively with diverse audiences both orally and in writing. Works with interdisciplinary teams to improve patient, family, and community outcomes. Electronically documents care according to industry and institutional standards. Program development and refinement in support of the Fortify Children’s Health mission and Fortify Cares priorities. Comprehensive and continuous assessment of patient and family including medical, social, educational and personal histories. Identification of and access to community resources to optimize effective and efficient care outcomes in collaboration with the multidisciplinary team. Advocating for patients and family members in conjunction with the healthcare team and Fortify team members. Patient-centered care planning that results in development, implementation, and ongoing evaluation of an individualized plan of care that is agreed-upon by the patient and family and communicated between care providers while ensuring patients and family members are actively informed of and participating in the care process in conjunction with the care team members. Ability to document and communicate in compliance with HIPAA and other regulatory guidelines. Education and support for patients and caregivers. Ongoing Identification and Referral to appropriate community resources based on assessment of needs. Consistent documentation that meets care, regulatory and accreditation requirements. Performs other duties as assigned.

Requirements

Graduate of Registered Nursing Program or LCSW required.
2+ years of relevant professional experience required.
Registered Nurse with current, unrestricted Virginia license, or Licensed Clinical Social Worker.

Nice To Haves

Strong understanding of Care Coordination best practices.
Proficient computer skills.
Strong organizational skills and the ability to work independently.
Excellent communication skills and the ability to interact with diverse individuals.
Bilingual (English/Spanish) preferred.
Experience working with children, families, community partners or in a behavioral health setting.
Prior work with Medicaid population a plus.
Experience conducting medication reconciliation with patients and identifying discrepancies.
Experience communicating with medical providers regarding patient needs.
Comfort working in a fast pace and dynamic “startup” environment.

Responsibilities

Completes assessments and develops individualized care plans.
Communicates with patients’ families telephonically.
Provides care that is inclusive and respectful of diverse patient populations.
Builds open, trusting, respectful relationships with diverse patients and families.
Applies clinical judgment to strategies designed to reduce risk factors and barriers.
Anticipates and responds to patient and family needs.
Solves unique barriers to communication and care.
Communicates effectively with diverse audiences both orally and in writing.
Works with interdisciplinary teams to improve patient, family, and community outcomes.
Electronically documents care according to industry and institutional standards.
Develops and refines programs in support of the Fortify Children’s Health mission.
Conducts comprehensive and continuous assessment of patient and family.
Identifies and facilitates access to community resources.
Advocates for patients and family members.
Develops, implements, and evaluates individualized plans of care.
Documents and communicates in compliance with HIPAA and other regulatory guidelines.
Provides education and support for patients and caregivers.
Identifies and refers patients to appropriate community resources.
Performs other duties as assigned.