In the role of an Social Work 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.
- 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.
