Healthy Equity - Social Worker - Population Health & Case Management 148-2004

Community Care•Tulsa, OK

About The Position

The Social Worker conducts care management and population health activities, including assessing member needs, coordinating care, and facilitating referrals for behavioral health and substance use services. The role monitors member outcomes and provider clinical performance to support quality, effectiveness, and continuity of care. The Social Worker develops person-centered care plans, connects members with community and healthcare resources, supports transitions of care, and collaborates with members, caregivers, providers, interdisciplinary teams, and community partners. The role also contributes to population health and quality improvement initiatives, conducts provider clinical chart audits and trainings as needed, and serves as a team resource for alternative care options. Accurate documentation and compliance with applicable regulations, accreditation standards, and company policies are required.

Requirements

Master's degree in a mental health field.
Active, unrestricted license to practice as a social worker in Oklahoma.
Active, unrestricted license to practice as a mental health professional in Oklahoma.
At least four years of related clinical experience in mental health.
Ability to rapidly and effectively diagnose mental health cases and refer members to appropriate levels of care.
Problem-solving and critical-thinking proficiency.
Experience working with complex, vulnerable, or high-risk populations.
Knowledge of social determinants of health.
Ability to communicate effectively with providers.
Fluency in spoken and written English.
Broad knowledge of community resources in the mental health field.
Proficiency with Microsoft Office applications.
Successful completion of a Health Care Sanctions background check.

Nice To Haves

Managed behavioral health experience.

Responsibilities

Conduct comprehensive psychosocial assessments to identify member needs, barriers to care, health-related social needs, and social determinants of health.
Evaluate member needs related to housing, food insecurity, transportation, financial strain, behavioral health, caregiver support, safety, health literacy, and access to community resources.
Develop individualized, person-centered care plans with members, caregivers, providers, and the interdisciplinary care team, including measurable goals and interventions.
Connect members to community-based organizations, public assistance programs, behavioral health services, long-term services and supports, and other appropriate resources.
Collaborate with physicians, nurses, behavioral health specialists, pharmacists, case managers, utilization management staff, and community partners.
Support transitions of care following hospitalizations, emergency department visits, skilled nursing facility stays, or other care transitions.
Assist members in navigating benefits, covered services, community support, and healthcare systems.
Participate in population health initiatives focused on preventive care, chronic condition management, health equity, and quality outcomes.
Use risk stratification tools, claims data, care gaps, utilization patterns, and referrals to prioritize outreach and interventions.
Support programs for high-risk, high-cost, vulnerable, or underserved populations and contribute to efforts to reduce avoidable emergency department visits, hospital readmissions, and gaps in care.
Document assessments, interventions, care plans, member contacts, referrals, outcomes, and case closure activities accurately and promptly in designated systems.
Maintain compliance with CMS requirements, URAC accreditation standards, HIPAA, privacy and security regulations, and company policies.
Monitor progress toward member goals and update care plans as needed.
Participate in quality improvement activities, interdisciplinary case conferences, and performance improvement initiatives.
Identify trends, barriers, and opportunities to improve population health outcomes and member experience.
Conduct provider clinical chart audits and provider trainings as needed.
Serve as a resource for the team on alternative care options.
Perform other job-related duties as required or assigned.