Location: Stewardship Health Inc
Posted Date: 7/26/2024
Job Type: Full Time
Department: 1185.72410 Managed Care
Position Purpose: Under the direction of the Manager, Social Determinants of Health (SDOH), the Care Manager (SDOH – CM) is a trusted member of the Care Management team who facilitates the care of high-risk patients faced with social determinant and behavioral health challenges to promote adherence to key components of their health care. The SDOH CM engages patients, creates a trusting relationship, and provides care coordination and management to patients with SDOH challenges who have high rates of emergency department and inpatient utilization and/or significant financial vulnerability. The SDOH - CM provides support and assists members in understanding the implications and complexities of their current situation and/or overall personal care.
Key Responsibilities:
- Provides face-to-face and/or telephonic care coordination and care management to patients with social determinant and behavioral health challenges who have high rates of Emergency Department and/or Inpatient utilization and/or severe psychosocial vulnerability.
- Provides care coordination and care management services to patients in the community and health care settings that patients access.
- Conducts comprehensive care needs assessments with patients, completing a care management treatment plan specific to each member.
- Assesses, plans, implements, monitors, and evaluates options and services to meet complex psychosocial health needs of patients.
- Addresses barriers to follow through on health care including, but not limited to homelessness/housing instability, financial resources, transportation, childcare, etc., and places referrals to community-based resources as necessary.
- Places external behavioral health and/or substance use community-based resources to assist patients in accessing quality and cost-effective care (i.e., outpatient therapy, medication management, day treatment, Child Behavioral Health Initiative Services, etc.).
- Reviews benefits options, researches community resources, trains/creates behavioral routines, and enables patients to be active participants in their own healthcare.
- Coordinates care with internal and external resources to meet identified needs of the patient's care plan and collaborates with providers.
- Monitors and evaluates the effectiveness of care plans and modifies plans as needed.
- Ensures patients are engaging with their PCP to complete their care management treatment plan or preventive care services.
- Acts as a liaison and advocate between the patient, family, physician, and facilities/agencies.
- Interacts continuously with members, family, physician(s), and other resources to determine appropriate behavioral action needed to address medical needs.
- Provides concise and thorough documentation through psycho/social assessment and progress notes, including changes in medical psycho/social functioning, progression and attainment of goals, referrals to internal and external agencies, and contact/involvement with the patient’s family.
- Demonstrates cultural sensitivity and respect for the patient.
Education:
- Bachelor’s Degree in Social Work, Psychology, Counseling, Rehabilitation, or another related field, preferred.
- BLS Certified (CPR/First Aid).
Years of Experience:
- At least two years of experience in social services care management and/or social services care setting focusing on outpatient/inpatient utilization, case management, and discharge planning.
Specialized Knowledge:
- Strong knowledge of Microsoft Office applications – Word, Excel, Access, PowerPoint, and SharePoint.
- Experience working with the needs of vulnerable populations who have chronic or complex bio-psychosocial needs.
- Experience working with disadvantaged populations, strongly preferred.
- Experience in a managed care environment and case management experience, preferred.
- Must be able to effectively communicate, present, and explain complex material with patients, family members, case managers, treating physicians, and community organizations.
- Must possess the interpersonal skills to engage individuals and families in helping relationships.
- Must be able to cope with the pressure of time limitations while respecting the needs of the patient and the requirements of the organization/department.
- Ability to act in solving problems while exhibiting judgment and a realistic understanding of issues; able to use reason, even when dealing with emotional topics.
- Ability to remain open-minded and change opinions based on information, perform a wide variety of tasks and change focus quickly as demands change, and manage transitions effectively from task to task.
- Ability to travel within the community, including valid driver’s license and auto liability insurance coverage according to company policy.
- Must possess a strong belief in an organizational culture that encourages valuing and best service excellence practices demonstrated through personal behavior and work ethic.
- Ability to work in several databases and to comply with established documentation requirements.
- Exceptional organizational skills; ability to multi-task and work independently and as part of a team.
- Demonstrate ability to prioritize, multitask, and work in a rapidly changing environment with multiple demands.
- Possesses knowledge and expertise of the healthcare system and resources available in the area in which CM- SDOH is providing care coordination/care management services.
- Demonstrates knowledge and understanding of the impact of the community and culture on health, illness, health practices, health beliefs, access to care, and participation in treatment and services.
- Working knowledge of community-based and government services and resources needed to assist patients in accessing services and addressing potential Social Determinants of Health.
About Steward Health Care
Over a decade ago, Steward Health Care System emerged as a different kind of health care company designed to usher in a new era of wellness. One that provides our patients better, more proactive care at a sustainable cost, our providers unrivaled coordination of care, and our communities greater prosperity and stability.
As the country's largest physician-led, minority-owned, integrated health care system, our doctors can be certain that we share their interests and those of their patients. Together we are on a mission to revolutionize the way health care is delivered - creating healthier lives, thriving communities, and a better world.
Based in Dallas, Steward currently operates more than 30 hospitals across Arizona, Arkansas, Florida, Louisiana, Massachusetts, Ohio, Pennsylvania, and Texas.
For more information, visit steward.org
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