Position Objective:

Endowed with clinical knowledge and experience, the Maryland Primary Care Program (MDPCP) Community Care Manager- SW works collaboratively with physicians, staff, and other health care professionals to provide care coordination and ensure that safety, best practices, and high quality standards are maintained across the continuum. S/he maintains knowledge of care management, behavioral health, social determinants of health, and chronic disease self-management resources available to patients and facilitates patients' adoption of supportive services. S/he plays an integral role in promoting access to appropriate community care resources, including transitional care services for vulnerable patients recently discharged from the hospital or ED, and providing care management to high-risk patients. S/he maintains access to and proficiency in programs including Epic, patient registries, and CRISP. Success will be measured by performance results at the practice and population levels.

Essential Job Duties:

1. Function as team subject matter expert in identifying the social determinants of heath and the optimal community resources to support high and rising risk patients in the self-care management.
2. Assist patients through healthcare continuum as a patient advocate, navigator, and liaison to team, providers and/or community resources.
3. Provide leadership to the team to improve care, community resource coordination, and manage the referral processes.
4. Facilitate health and disease patient education and support patient self-management of disease and behavior modification interventions.
5. Collaborate with patients, care team, and providers to understand patient short and long-term goals and contribute to patient longitudinal plan of care.
6. Coordinate continuity of patient care with providers across the healthcare system, including post-hospital or ED discharge.
7. Use high-risk screening criteria to identify and manage high-risk patients, including patients with multiple comorbidities or are at risk of avoidable utilization/ readmission.
8. Participate on teams for data collection, health outcomes reporting, clinical audits, and programmatic evaluations related to the Maryland Primary Care Program (MDPCP), and quality improvement initiatives.
9. Evaluate the psycho-social clinical plan of care, resource utilization, and contribute to the development of new tools, forms, and procedures.
10. Contribute to the performance evaluation of team members.

Educational/Experience Requirements:

• Master's degree with a focus in social work. LCSW - C required (or obtained within 6 months of employment)
• At least 5 years of experience in healthcare with care management experience.

RequiredLicense/Certifications:

• Required License/Certification: Licensed Certified Social Worker (LCSW) or Licensed Certified Social Worker Clinical (LCSW-C) from the Maryland Board of Social Work Examiners or other approved designated Social Worker license/certification. If Licensed Certified Social Worker (LCSW) must obtain Licensed Certified Social Worker Clinical (LCSW-C) within 6 months of hire.
• Current American Health Association Health Care Provider Basic Life Support (BLS) CPR certification.
• Case Management Certification strongly preferred

Working Conditions, Equipment, Physical Demands:

There is a reasonable expectation that employees in this position will not be exposed to blood-borne pathogens.

Physical Demands - Light Duty

The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.

The above job description is an overview of the functions and requirements for this position. This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.