Social Work Care Manager

Fallon Health•Worcester, MA

About The Position

The Social Work Care Manager (SWCM) works very closely with Fallon Health Care Team staff, Provider Partners, Community Partners,and/ or community-based groups to address service gaps and serves as a liaison to social and health resources on behalf of Fallon Healthand the Fallon Health Care Management Models of Care. The SWCM collaborates and coordinates with State Agencies, DMH, DDS, DYS, DCF to ensure members care is efficient and coordinated.The SWCM provides social service coordination services to members as referred assessing member needs, services and resources toaddress social, health, or economic needs and facilitates referrals and collaboration with Provider Care Teams and BH Partners in thecommunity. The SWCM assists the member and or family to provide care utilizing FH benefits and/or community resources developing a plan tocoordinate a continuum of care consistent with the members’ health care needs and/or goals. The SWCM uses their knowledge of benefitplan design, eligibility and/or financing alternatives available within the community to provide options that meet member’s needs.The SWCM identifies services, care delivery settings, and funding arrangements that meet the needs of the members. They recommendsalternatives where appropriate. The SWCM monitors services and provides consistent feedback to the team on progress. The SWCM collaborates and works with members of the Care Team both at Fallon Health and at the Community Partners during time ofmember transition of care. May attend in person care planning meetings, care coordination meetings, partner communication meetings, and other face-to-facemeetings with providers, partners, and members to perform assessments, train staff, coordination communication and otherwise representFallon Health in a positive way. SWCM seeks to establish telephonic and/or face to face relationships with the member/caregiver(s) to better ensure ongoing serviceprovision and care coordination, consistent with the member specific care plan developed by the BHCM and Care Team.Responsibilities may include conducting in home/office face to face visits for member identified as needing face to face visit interaction andassessments with the goal to coordinate and facilitate services to meet member needs according to benefit structures and availablecommunity resources. The SWCM conducts assessments and refers members to community resources. The SWCM may utilize an ACDline to support department and incoming/outgoing calls with the goal of first call resolution with each interaction.

Requirements

Master’s degree from an accredited school of social work, mental health counseling, psychology, or human services required
Certification in Case Management a plusOther: Satisfactory Criminal Offender Record Information (CORI) results
Four years of experience working with the following: the chronically ill, SPMI, and substance use populations required
Experience and comfort conducting face-to-face visits with members in the community and in home settings required
Experience working in a multi-disciplinary care team required
Experience working and providing collaborative care management interventions with various State Agencies such as DMH, DDS, DCF, DYS required
Experience working with provider groups such as medical and/or mental health providers required

Nice To Haves

Certification in Case Management a plus
Background working with all age groups preferred
Previous experience working at a Managed Care Organization preferred

Responsibilities

Provides culturally appropriate care coordination, i.e., works with interpreters, provides communication approved documents in the appropriate language, and demonstrates culturally appropriate behavior when working with member, family, caregivers, and/or authorized representatives
With member/authorized representative(s) collaboration develops member centered care plans by identifying member care needs while completing program assessments and working with the Care Coordinator to ensure the member approves their care plan
Monitors progression of member goals and care plan goals, provides feedback and works collaboratively with care team members and work effectively in a team model approach to coordinate a continuum of care consistent with the Member’s health care goals and needs
Actively participates in internal clinical rounds and huddles
Works with members of the Utilization Management Department assisting with difficult or complex care delivery or discharge planning needs for members
Actively participate with Beacon team and collaborate on high-risk members to decrease utilization
May collaborate with staff on site to facilitate communication between Fallon and community-based teams
Assists with care coordination with community Partners to engage in Interdisciplinary team meetings
Works with Nurse Case Managers and Navigators to coordinate a continuum of care for members consistent with the member’s health care goals and needs
Maintains an ongoing awareness of clinical, social, and financial resources available in the community as well as State/Federal and National Resources and connects and advocates for members as appropriate
Performs other responsibilities as assigned by a member of the Clinical Integration Leadership Team
May attend in person member/provider visits, care plan meetings with providers and office staff and may lead care plan review with providers and care team as applicable
Demonstrates positive customer service actions and takes responsibility to ensure member and provider requests and needs are met
Completes Program Assessments, Notes, Screenings, and Care Plans in the TruCare and Provider EMR systems according to Program policies and processes
Offers recommendations to continued program development and is an active participant in suggesting opportunities to enhance the program
Works with Fallon Health Provider Relations and Beacon Health Options to ensure that contracted behavioral health providers are knowledgable about the plan benefits, eligibility requirements, and care coordination and communication needs
Coordinate with Beacon staff to ensure quality and timely arrangement of necessary mental health and substance use supports.
Attends Fallon Health/Beacon meetings when requested
Attends supervision and 1:1 meetings with Leader. Attends Team Huddles, staff meetings, site meetings and other Fallon Health and business related meetings as required. Meetings may be in person or telephonic depending upon the need
Performs other responsibilities as assigned by the Manager/designee
Supports department colleagues, covering and assuming changes in assignment as assigned by Manager/designee