Case Manager Continuing Care Social Work

• Plans, develops, assesses and evaluates care provided to members.


• In conjunction with primary care and specialist physicians, evaluates and develops baseline medical and psychosocial evaluations and individualized patient care/treatment plans.


• Recommends alternative levels of care and ensures compliance with federal, state, and local requirements.


• Makes assessments of physiological and or functional status utilizing protocols.


• Initiates appropriate diagnostic testing/screening and interventions.


• Develops individualized patient/family education plan focused on self-management; delivers patient/family education specific to a disease state.


• Implements strategies to target/assess risk factors and achieve and ensure patient follow-up according to clinical and strategic measures/outcomes.


• Produces population based reports on outcomes specific to defined patient populations.


• Participates with healthcare team/providers in actualizing outcomes by planning, evaluating and implementing decisions and strategies to achieve predetermined cost, clinical, quality, utilization and service outcomes.


• Develops and maintains case management policies and procedures.


• Coordinates care/services with utilization and/or quality reviewers and monitors level and quality of care.


• Coordinates the interdisciplinary approach to providing continuity of care, including utilization management, transfer coordination, discharge planning, and obtaining all authorizations/approvals/transfers as needed for outside services for patients/families.


• Consults with internal and external physicians, health care providers, discharge planning and outside agencies regarding continued care/treatment or hospitalization or referral to support services or placement.


• Arranges and monitors follow-up appointments.


• Encourages member to follow prescribed course of care (e.g., drug therapy, physical therapy).


• Makes referrals to appropriate community services and outside providers.


• Identifies and recommends opportunities for cost savings and improving the quality of care across the continuum.


• Develops and collects data; trends utilization of health care resources.


• Interprets regulations, health plan benefits, policies, and procedures for members, physicians, medical office staff, contract providers, and outside agencies.


• Coordinates transmission of clinical and benefit treatment to patients, families and outside agencies.


• Acts as liaison for outside agencies, non-plan facilities, and outside providers.


• Coordinates repatriation of patients and monitors their quality of care.

• N/A.

• Graduate of an academic institution accredited by the Council on Social Work Education and a Masters degree in Social Work.

• N/A

• Demonstrated knowledge of case management, discharge planning, transfer coordination; TJC and other federal/state/local regulations.


• Must be able to work in a Labor/Management Partnership environment.

• Minimum two (2) years of case management experience with the population to be case managed preferred.


• Current and valid LCSW highly preferred.

Notes:

• for Special Needs Program