Full-Time: 40 Hours Per Week
1st Shift: 8am - 4:30pm
Monday - Friday w/Occasional Nights/Weekends
Department: Palliative Care - Onsite

Summary:

The Social Work (SW) Care Manager Plus, under the direction of a department Supervisor, applies graduate-level clinical social work skills to provide comprehensive, family-centered care management services to pediatric and young adult patients, included attributed managed care members, with complex medical, behavioral health, and psychosocial needs. This role applies the social work practice process (engagement, assessment, planning, intervention, monitoring, and evaluation) to ensure compliance with NCQA Complex Care Management (CCM) standards, promote interdisciplinary collaboration, improve population health outcomes, and reduce overall cost of care. The SW Care Manager Plus partners with children and young adults, and their caregivers to address social drivers of health, enhance access to services, and support optimal health and well-being.

Responsibilities:

1. Establish therapeutic, culturally responsive relationships with patients and caregivers to promote engagement, trust, shared decision-making, and active participation in care management services.

2. Conduct comprehensive biopsychosocial assessments, including medical, behavioral health, developmental, educational, family, environmental, and social drivers of health factors, to identify patient and caregiver needs, risks, strengths, and barriers to care.
3. Identify high-risk and complex patients using established stratification criteria, referral sources, and population health methodologies to prioritize interventions and resource utilization.
4. Develop, implement, and maintain individualized, family-centered care plans that integrate medical, behavioral health, educational, psychosocial, and community-based interventions while reflecting patient preferences, cultural considerations, and trauma-informed principles.
5. Coordinate care across the healthcare continuum, including primary care, specialty care, hospitals, home health, schools, and community agencies to ensure timely access to appropriate, cost-effective, and high-quality services.
6. Advocate for patients and families by facilitating access to resources, addressing social drivers of health, resolving barriers to care, and supporting achievement of individualized care goals.
7. Provide supportive counseling, crisis intervention, and care management services to patients and caregivers while participating in interdisciplinary care team meetings, case reviews, and care conferences.
8. Monitor patient progress, healthcare utilization, treatment adherence, caregiver engagement, and changes in risk status; revise care plans and interventions as needed in collaboration with patients, families, and the interdisciplinary team.
9.  Evaluate the effectiveness of care management interventions and outcomes related to psychosocial well-being, patient experience, quality of care, population health, and achievement of established goals.
10. Document assessments, interventions, care plans, and outcomes in accordance with organizational policies, professional standards, and regulatory requirements; maintain compliance with applicable accreditation, quality, confidentiality, and ethical practice standards.

Other information:

Technical Expertise

1. Knowledge of pediatric health conditions, family dynamics, and child development principles applied through family-centered, trauma-informed, and culturally competent methodology.

2. Strong psychosocial assessment, crisis intervention, critical-thinking, and motivational interviewing skills with ability to manage and prioritize caseload effectively.
3. Excellent communication and collaboration skills with a commitment to quality improvement and cost-effective care delivery.
4. Familiarity with healthcare systems, insurance processes, and community resources.
5. Proficiency in MS Office [Outlook, Excel, Word] or similar software is required. Epic software or similar EMR software is preferred.

Education and Experience

1. Education: Master's degree in social work from an accredited Social Work academic program is required.

2. Licensure: Current, unrestricted licensure as a Licensed Social Worker (LSW) in Ohio is required.
3. Certification: Certification by a nationally recognized care management organization is preferred.
4. Years of relevant experience: Minimum 2 years of clinical experience in healthcare required. Experience in pediatric, ambulatory, care management and/or managed care is preferred.
5. Years of supervisory experience: none

Full Time

FTE: 1.000000

Status: Onsite