Master of Social Work (ECM)

Central Neighborhood Hlth Fdn•San Bernardino, CA

About The Position

The Enhanced Care Management program provides a whole-person approach to care that addresses the clinical and non-clinical circumstances of high-need members enrolled in MediCal managed care health plans. The MSW Lead Care Manager will work with leadership, providers and managed care plans to determine the needs of high-acuity, vulnerable patients. This will include providing basic housing assistance, patient tailored intensive case-management, and developing a care/service plan. Provide linkages to medical, psychiatric, social, educational and other supportive services as needed. The MSW Lead Care Manager will also work with the Community Supports Program staff to provide team-based, patient-centered care management for homeless and at-risk of homelessness patients. The goal of the ECM program is to effectively manage high utilizers and homeless patients during their continued care to ensure that their medical and psychosocial needs are met and to minimize the likelihood of preventable hospital admissions and emergency department utilization.

Requirements

Master’s degree required.
Three years of experience in health care, case management, or a related field.
Knowledge and experience with Electronic Medical Records.
Ability to communicate effectively in both written and verbal form to patients, public, medical staff, and physicians.
Excellent counseling skills and ability to relate to multi-ethnic communities and varied income levels.
Strong interpersonal skills to establish productive working relationships with a multidisciplinary team and support services.
Ability to work independently, collaboratively, and possess strong time management skills.
Knowledge of the Care Process and ability to apply all steps.
Knowledge of insurance coverage and the insurance eligibility process.
Knowledge of the functions and services of local community health agencies and community organizations.
Excellent organizational skills and attention to detail.

Nice To Haves

ACSW preferred, not required.

Responsibilities

Conducts initial screening, assessments, and reassessments to determine the continued needs of the client.
Conducts outreach, enrollment, monthly reporting, and accurate completion of comprehensive risk assessments and care plans.
Conducts proper intake steps such as patient data collection, eligibility, program enrollment, care plan development, and assessment of needs.
Documents in EMR and external health plan portals.
Works with leadership, providers, and managed care plans to develop and implement patient-focused care plans for clients with chronic conditions.
Provides direct care management services to ECM participants in their assigned case load in line with ECM guidelines and recommended services.
Conducts regular reviews of patients’ charts to ensure quality services are provided and documented by Lead Care Managers consistently and accurately.
Responds to patient inquiries and refers members to other departments, social services, or support services as needed.
Works with the Housing Navigation team to ensure enrolled patients, who are experiencing homelessness or are at risk of homelessness, receive proper services.
Performs other related duties as assigned.