Social Work Care Manager (DSNP)

About the role

The Social Work Care Manager for Belong Health's DSNP program is responsible for providing comprehensive, member-centered care management services for Medicare beneficiaries with complex medical, behavioral health, and social needs. This role applies care management principles to assess member needs, develop and implement individualized care plans, coordinate services across the continuum of care, and maintain collaborative relationships with provider practices, community-based organizations, caregivers, and the Belong Health team. The Social Work Care Manager utilizes expertise in behavioral health, psychosocial assessment, crisis intervention, motivational interviewing, and care coordination to identify and address barriers to care, support member engagement, and ensure medical, behavioral health, and social determinants of health needs are integrated into a comprehensive plan of care. ESSENTIAL JOB DUTIES AND RESPONSIBILITIES Responsible for providing comprehensive care management services to Medicare beneficiaries with complex medical, behavioral health, and social needs. Orient new members to the Belong Health DSNP program and educate members and/or caregivers on care management services. Advocate, empower, inform, and educate beneficiaries on self-management techniques, behavior change strategies, and available community resources. Conduct comprehensive biopsychosocial assessments to identify barriers to care, unmet needs, and opportunities for intervention. Complete health risk assessments, reassessments, psychosocial evaluations, and other assessments in accordance with program requirements. Identify members requiring intensive care management interventions and coordinate appropriate clinical, behavioral health, social service, and community-based supports. Develop and implement an Individualized Care Plan (ICP) that addresses medical, behavioral health, and social determinants of health needs. Monitor member progress toward care plan goals and revise interventions based on changing clinical, behavioral health, or social needs. Lead and participate in interdisciplinary care team meetings. Collaborate with providers, social workers, discharge planners, behavioral health professionals, caregivers, and community-based service providers to coordinate care and achieve care plan goals. Support transitions of care activities, including post-discharge outreach, assessment of psychosocial needs, medication reconciliation support, and coordination with providers and caregivers. Provide crisis intervention, behavioral health support, and resource navigation as appropriate within the scope of licensure and organizational protocols. Facilitate referrals and connections to behavioral health services, social services, financial assistance programs, housing resources, transportation services, and other community-based supports as appropriate. Document all care management activities in the appropriate system in accordance with internal policies and established documentation procedures. Work directly with members, their families and/or advocates, providers, and community service organizations on an ongoing basis to coordinate care and reduce barriers to care. Utilize population health, risk stratification, and care management technology platforms to prioritize outreach and interventions. Promote a culture of accountability and performance to both meet and exceed personal service vision goals and ensure timely and satisfactory resolution of highly complex, specialized, and non-routine member issues. Maintain knowledge of community resources, behavioral health services, and social support programs to effectively address member needs. Other duties as assigned. SUPERVISORY RESPONSIBILITIES This role does not have supervisory responsibilities. REQUIRED PROFESSIONAL EXPERIENCE AND QUALIFICATIONS Current unrestricted license in a behavioral health discipline required, including LMSW, LCSW, LMHC, or equivalent licensure as permitted by state regulations. Advanced clinical licensure (e.g., LCSW) preferred. Working knowledge of Medicare and Medicaid programs and experience with regulatory requirements and reporting. Proficient in navigating multiple systems; demonstrated PC skills using Microsoft applications. Two (2) or more years' experience in a health plan, health care organization, Community Based Organization, behavioral health organization, or social services environmen

Benefits

Additional Information

Hello, we're Belong. We partner with regional payers to deliver Medicare Advantage and Special Needs Plan products. With a dual focus on data-driven, proactive clinical intervention and unwaveringly empathetic patient experience, Belong has completely reimagined health insurance for seniors and other Medicare-eligible individuals who have been disregarded and deprioritized for far too long. We believe that only by recognizing individuals can we make communities strong. Belong Health. Kinder, more supportive care.

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