ToC Social Worker Baltimore

Maryland Care Management Inc•Baltimore, MD

52d•Hybrid

About The Position

The Social Worker on the Transition of Care (TOC) team supports high-risk members at a critical point in their care by addressing complex social barriers and helping guide a successful return to the community following hospitalization. Working collaboratively with facility case managers, nurses, and an interdisciplinary care team, the TOC Social Worker provides short-term, high-impact interventions focused on stabilization, safety, and connection to community resources. You will meet members where they are—often face-to-face—and use clinical judgment, motivational interviewing, and problem-solving skills to support recovery, independence, and continuity of care.

Requirements

Master’s degree in social work.
Maryland state LMSW/LCSW or LCSW-C licensure.
At least 1 yr experience in a community-based, hospital, or discharge planning setting addressing social needs and care transitions.
Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.
Knowledge of community agencies and resources.
Working knowledge of multi-system outreach programs related to health care delivery, clinical education, and health-related services.
Ability to plan, implement, and evaluate individual member care plans.
Knowledge of change management, behavioral change management, transportation/food/safety resources.
Possession of a valid MD State Driver’s License.

Nice To Haves

Knowledge of government-managed care programs preferred.

Responsibilities

Evaluate members based on their needs and limitations based on referrals.
Will work directly with the Hospital/SNF case management staff to assist with the coordination of care and discharge plans for identified members.
Will collaborate directly with members and their families to build a rapport to assist with discharge needs as appropriate.
Address member concerns and goals while maintaining constant communication with the member.
Utilizes clinical judgement to assess members, prioritizing emerging issues to maintain a member-centric approach.
Collaborates with interdisciplinary care team at the facilities to support member health goals via conference calls, rounds, and consultation, which may include face-to-face meetings.
Complete assessments to better understand the Social Determinants of health and social issues impacting member care goals.
Utilizes problem-solving skills to research and identify community resources and coordinate a referral mechanism.
Plans specific objectives, goals, and actions designed to meet the members’ needs as identified in the assessment process that are action-oriented, time-specific, and cost-effective.
Implements specific activities and/or interventions that lead to accomplishing the goals outlined in the plan of care.
Develop trusting relationships with members by providing support and advocacy to help achieve health goals.
Monitors care management activities, services, and members’ responses to interventions, to determine the effectiveness of the plan of care and the utilization of services.
Evaluate the effectiveness of the plan of care in reaching desired outcomes and goals; makes modifications or changes in the plan of care as needed.
Make connections with members through visits to the hospital, home, and community via face-to-face, telephonic and/or video conferencing.
Participates in outreach activities to promote knowledge of the program and its services and to coordinate program activities with outside community agencies and health care providers.
Work with the MPC Case Management Team for an appropriate transition of care.
Observe confidentiality of member records in accordance with MPC policies and procedures.