Social Worker- Care Management

Central Ohio Primary Care•Columbus, OH

7d•Hybrid

About The Position

The Care Manager, Social Worker is responsible for identifying and understanding community-based resources and connecting patients with these resources as needed. Our patient population is primarily Medicaid-insured and underinsured, often facing barriers such as housing instability, food insecurity, transportation challenges, and untreated mental health conditions. The Social Worker plays a critical role in improving health outcomes by addressing these social determinants of health. You will work side-by-side with primary care providers, nurses, and care coordinators to deliver whole-person, patient-centered care.

Requirements

Five years or more clinical and care management experience in hospital, home health/hospice, or managed care setting
Licensed Social Worker in the state of Ohio
Active Ohio driver's license with the ability to travel throughout COPC's service area as needed
Previous experience working with Medicaid patients; knowledge of Medicaid rules and regulations
Proficient in computer software and usage including but not limited to Microsoft Outlook and Microsoft Excel
Knowledge of community resources and behavioral needs for adult population
Knowledge of trends in healthcare, managed care, Medicaid, case management, medical management and quality improvement
Demonstrate awareness and ability to work alongside diverse cultures and patient populations
Ability to create positive working relationships with physicians and other members of the health care team
Ability to demonstrate work toward the progress of patient-centered goals
Ability to adapt to changing environment
Ability to work independently and within a team environment with minimal supervision
Excellent negotiation and advanced conflict resolution skills
Strong analytical, organizational, and time management skills
Strong written and verbal communication skills; ability to communicate effectively in stressful situations
Self-disciplined, energetic, passionate, and innovative
Decision making/problem solving and training/teaching skills
Critical and ‘systems' thinker with strong attention to detail

Nice To Haves

Previous experience with epic and hospice and palliative services
Master's degree in Social Work
Epic EHR system experience

Responsibilities

Complete patient assessments to evaluate all social, psychological, or environmental needs related to the impact of admission, diagnosis, treatment, or discharge.
Provide patient/caregiver with education, information, and referral services.
Provide patient/caregiver with relevant information about medical illness, behavioral health, insurance coverage, support, and community services.
Develop plan of care for patients in collaboration with the primary care team.
Document in the medical record as indicated and designated case management tool accurately.
Provide ongoing communication between the patient and health care team to ensure improved patient outcomes and high quality of patient care.
Conduct end-of-life discussions with patient/family, as needed.
Facilitate referrals to other disciplines and internal health and community based programs as needed to improve patient outcomes.
Coordinate and participate in interdisciplinary patient/caregiver conferences.
Participate in departmental process improvement initiatives, work on special projects as needed and attend all departmental meetings.
Serve as an advocate and resource for the patient/caregiver.
Provide temporary case management to a specified case load.