In the role of an SW Care Manager, you will partner with the Registered Nurse and are a critical resource for our members as you are responsible for obtaining needed medical, social, educational, psychosocial, financial, and other services, irrespective of whether the needed services are covered Elderwood IPA.
In Addition, assisting the RN Care Manager where necessary with assessing a member’s home health and level of care needs, assisting them in accessing necessary covered services, providing referrals and coordinating other medical services in support of their member centric service plan.
- Direct telephonic and in-person engagement with individuals with chronic medical illness or mental health issues and their families.
- Utilize assessment tools to determine the needs of our member population
- Link members to resources in the community outside of the scope of services MLTC provides to support social determinants of health.
- Interacts continuously with members, family, physician(s), and other resources to determine appropriate behavioral action needed to address/support medical needs.
- Reviews benefits options, research community resources, coordinates services, trains/creates behavioral routines and enables members to be active participants in their own healthcare.
- Documents in the EMR each encounter or routine contact with members, providers or caregivers and reports changes in conditions to the RN Care Manager, which may require interventions.
- Participate in Interdisciplinary Team meetings, Disease Management, Utilization Management, and Quality Improvement activities and prepare/submit activity reports.
- Provide coaching and education to members and their caregivers on health care related issues
- Provide discharge planning and continuous care management across care settings and coordinate the transition planning
- Participate in shared on-call, after-hours coverage along with other Elderwood staff.
