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ChenMed · 2 days ago

Social Complex Care Manager, SW

Greenacres, FL

Full-time

Hybrid

Mid Level

$54K/yr - $78K/yr

ChenMed is transforming healthcare for seniors and changing America’s healthcare for the better. The Social Complex Care Manager is responsible for providing psychosocial assessment, social case work, and linkage to community resources for patients with chronic diseases, advocating for services for underprivileged individuals and ensuring compliance with departmental goals and quality patient care standards.

Health CarePrimary and Urgent Care

Responsibilities

Conducts timely and appropriate assessment and needs identification, prioritizing patients on the 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 contributed to hospitalization

Dialogues with PCPs in order to support and advise concerning social needs and resources available

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, DME, HHA. etc

Serves as care coordinator, linking patients with internal and external resources, prioritizing patients on the PCP’s HPP and Top 40 patient lists

Facilitates connections to community resources as identified by the patient’s SDoH Wellness Screening

Works with patient, family, and case manager to facilitate applications for higher level of care

Works to provide self-management support and ongoing phone contact with patients

Maintains an accurate repository of social wellness tools for the care team’s awareness and utilization

Maintains communication with other healthcare team members by attending appropriate meetings (i.e. weekly Super Huddles and Transitional Care Team meeting.)

Provides consultation in an integrated health care environment regarding social determinants of health and community resources

Maintains timely, accurate, thorough and appropriate documentation/reports per company policies and procedures. Initial psychosocial assessments will be completed withing 48 hours. All follow up visits phone calls and collaborative contacts will be documented within 24 hours. Assures documentation meets billing guidelines

Works closely with the transitional 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

Qualification

Social Work KnowledgeCommunity Resource CoordinationPsychosocial AssessmentPalliative Care KnowledgeElectronic Medical RecordsDocumentation ProficiencyCultural SensitivityMicrosoft Office SuiteIndependent JudgmentFluency in EnglishTeamwork SkillsCommunication SkillsCritical Thinking

Required

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 resources

Teamwork skills in care coordination with patients, family systems, staff, and external providers

Ability to work autonomously is required

Ability to monitor, assess and record patients' progress and adjust accordingly

Ability to communicate technical information to non-technical personnel, and with patients and/or their family systems

Strong interpersonal, communication and critical thinking skills and the ability to work effectively with a wide range of constituencies in a diverse community

Demonstrated ability to provide care effectively and sensitively to people from different cultural groups

Ability to create a collaborative relationship to maximize the patient's/family's ability to make informed decisions

Proficiency in written communication: documentation is clear, concise, accurate, provides meaningful communication and is consistent with company policy and regulatory requirements

Proficiency in technology, including the utilization of Electronic Medical Record platforms for care coordination

Proficient in Microsoft Office Suite products including Word, Excel, PowerPoint and Outlook, plus a variety of other word-processing, spreadsheet, database, e-mail and presentation software

Ability and willingness to travel locally, regionally and nationwide up to 30% of the time

Spoken and written fluency in English

This job requires use and exercise of independent judgment