Supports the overall improvement of members health status in collaboration with the case managers and physicians by identifying and referring members to community resources, counseling and/or support services. Educates members about entitlement programs, legal issues, or other services relevant to social work practice skills and knowledge. Work in partnership with the member and community partnerships to develop and implement a plan of care.
- Use the case management process to assess, develop, implement, monitor, and evaluate care plans designed to optimize the members’ health across the care continuum.
- Consult and coordinate with the case manager and physician to identify member issues and develop a plan to resolve the issues.
- Utilize available government, community and/or employer group resources to address member’s unique needs.
- Facilitate and coordinate Behavioral Health resources as individual needs are identified.
- Manage behavioral, psychosocial needs and deliver social work interventions.
- Identify and refer members to community resources, counseling, and/or support for the member and/or authorized representative, as needed.
- Arrange resources necessary to meet identified needs (e.g., community resources, mental health services, substance abuse services, financial support services and disease-specific services).
- Assess the members’ progress to social work intervention and community services provided through on site visits and POD review sessions upon invitation.
- Assist the Case Manager with psychosocial needs assessment and identification of appropriate resources as needed.
- Document all activities as appropriate, including but not limited to member assessment, communication with case managers, PCP or issues related to guardianship, abuse/neglect.
- Evaluate members’ availability to independently manage self and locate resources.
- Educate the member and/or authorized representative about entitlement programs (i.e., Medicaid, Social Security), legal issues (i.e., guardianship, advanced directives) and assisting in the application process as needed.
- Assist the member and/or authorized representative with long-term care planning and of end-of-life decisions and options as needed.
- Provide member support as needed throughout hospice period.
- Provide members receiving hospice services with information regarding appropriate community resources.
- Participate in multi-disciplinary team conferences.
- Adhere to professional standards as outlined by protocols, rules and guidelines meeting quality and production goals.
- Continue professional development by completing relevant continuing education and maintaining Certified Case Manager (CCM).
Departmental Preferences
- Candidates with home health care and/or behavioral case management experience preferred.
"Qualifications"
- Master’s Degree in Social Work or Psychology required.
- Minimum of 3 years of practice as a Licensed Master’s Social Worker required.
- Minimum of two (2) years to be in home health care and/or behavioral case management preferred.
- Experience managing patients telephonically and via digital channels (mobile applications and messaging) preferred.
- Currently unrestricted Licensed Master’s Social Worker in the State of Michigan is required.
- Certification in Case Management (CCM) preferred or to be obtained within 18 months of hire.
- Ability to think critically, be decisive and problem solve a variety of topics that can impact a member’s outcomes.
- Knowledge of HIPAA regulations and guidelines, American Disability Act and Clinical Ethics.
- Knowledge of BCBSM/BCN benefits preferred.
- Ability to engage and motivate the member or member representative, mentor, and train.
- Identify existing and or potential psychosocial and quality of care issues.
- Empathetic, supportive and a good listener.
- Proficient in motivational interviewing skills.
- Demonstrated time management skills.
- Organizational skills with the ability to manage multiple systems/tools, while simultaneously interacting with members.
- Must have intermediate computer knowledge, typing capability and proficiency in Microsoft programs (Excel, OneNote, Outlook, Teams, Word, etc.).
- Must embrace teamwork but can also work independently.
- Identify existing and or potential psychosocial and quality of care issues.
- Interact and collaborate with multidisciplinary team while advocating on member’s behalf.
- Excellent interpersonal and communication skills both written and verbal.
All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.
