Social Complex Care Manager, SW

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We're unique. You should be, too. We're changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy? We're different than most primary care providers. We're rapidly expanding and we need great people to join our team. The Social Complex Care Manager, SW, is a Community Social Worker that works closely with the PCP, Medical Specialists and other members of the Complex Care team such as Post Hospital Care Coordinators, Post Hospital Care Manager, Hospital Care Managers, and Intensive Community Case Managers. The incumbent in this role is responsible for providing psychosocial assessment, social case work and linkage to community resources for complex patients who have chronic, life threatening or altering diseases and disorders and may be at high risk for hospitalization. The incumbent in this profile advocates for services and resources for the underprivileged and victims of abuse, neglect, or other difficult personal situations to help them maintain an optimum level of health and prevent hospital arrivals. Community Social Workers will adhere to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance, and policies and procedures as defined by industry standards and the enterprise. The success of this role is determined by the impact social needs management has on patients with complex social needs on preventing unnecessary hospital arrivals. ESSENTIAL JOB DUTIES/RESPONSIBILITIES: Needs Identification and assessment: Conducts timely and appropriate assessment and needs identification, prioritizing patients on the Intensive Community Care (ICC) program, PCP's High Priority Patients (HPP) and Top 40 patient lists. Assesses the patients for psychosocial, financial, family issues, palliative care/end of life issues, home safety, etc. that negatively impact their health outcomes and at risk for hospitalization. Communicates with PCPs and interdisciplinary Care Team in order to support and advise concerning social needs and resources available in community resource database. Medicaid and other benefit eligibility assessments: Conducts appropriate assessment of needs and financial benefit eligibility. Assesses patients for Medicaid criteria and assists with application process as needed. Assists patients to obtain community resources/services as appropriate, e.g. meals, medications, housing, daycare, HHA and other SDoH needs as identified. Resource coordination and prevention: Serves as care coordinator linking patients with internal and external resources, prioritizing complex patients whose needs can lead to unnecessary hospital arrivals. Educates center staff, other members of the care team, patients and caregivers on how to access community resources as identified by the patients SDoH Wellness Screening. Works with patient, family, and interdisciplinary care team to facilitate applications for higher level of care. Maintains an accurate repository of social wellness tools and resources for the care team's awareness and utilization with patients in need. Communication: Maintains communication with interdisciplinary team members by attending appropriate meetings (i.e. weekly Super Huddles and Hospital and Community Care Team (HCT) meeting.) Provides consultation in an integrated health care environment regarding social determinants of health and community resources. Timely and accurate documentation: Maintains timely, accurate, thorough and appropriate documentation/reports per company policies and procedures. Initial psychosocial assessments will be completed within 48 hours. All follow- up visits, phone calls and collaborative contacts will be documented within 24 hours. Assures documentation meets billing guidelines. Additional duties may include: Works closely with the Complex Care Team to secure the appropriate level of care post hospital/SNF discharge. Further interventions may be conducted in the center, by phone call or patient's home. Performs other duties as assigned and modified at manager's discretion. KNOWLEDGE, SKILLS AND ABILITIES: Keen business acuity and acumen Full knowledge and understanding of general Social Worker functions, practices, processes, procedures and techniques Knowledge of social services documentation procedures and standards Knowledge of community health services and social services support agencies and networks Knowledge of normative changes (e.g., sensory, cognitive, psychosocial) associated with aging for high-risk patients Knowledge of advance care planning and palliative care, and related skill in addressing advance care planning Ethical practice behavior consistent with ChenMed policies and professional standard Skill in psychosocial interventions with challenged caregivers/family systems of high-risk patients Appropriate utilization of community-based reso

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