Central Ohio Primary Care Physicians is seeking a Care Manager, Social Worker to join our Comprehensive Care team located in Westerville, OH. The Care Manager, Social Worker works closely with Physicians, Nurse Care Managers, Pharmacists, and other care team members to provide and develop plan of care. Responsibilities include assessing and managing transition plans for patients who are at high risk for readmission for social, psychological and/or environmental needs related to the impact of admission, diagnosis, treatment, and discharge. This position receives referrals from across the network of Physicians, working closely with transition of care Nurses and Nurse Care Coordinators to identify high-risk patients who are appropriate for disease or care management programs. The Care Manager, Social Worker is responsible for identifying and understanding community-based resources and connecting patients with these resources as needed. This is full time position working Monday- Friday 8a-5p.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:

• Complete patient assessments to evaluate all social, psychological, or environmental needs related to the impact of admission, diagnosis, treatment, or discharge.
• Provide patient/caregiver with education, information, and referral services. Provide patient/caregiver with relevant information about medical illness, behavioral health, insurance coverage, support, and community services.
• Develop plan of care for patients in collaboration with the primary care team. Document in the medical record as indicated and designated case management tool accurately.
• Perform Face-to-Faces as necessary including home, office and skilled rehab facility settings . Evaluate possible barriers to attainment of self-management goals and develop strategies to overcome.
• Provide ongoing communication between the patient and health care team to ensure improved patient outcomes and high quality of patient care. Conduct end-of-life discussions with patient/family, as needed.
• Facilitate referrals to other disciplines and internal health and community based programs as needed to improve patient outcomes. Coordinate and participate in interdisciplinary patient/caregiver conferences.
• Participate in departmental process improvement initiatives, work on special projects as needed and attend all departmental meetings.
• Serve as an advocate and resource for the patient/caregiver.
• Provide temporary case management to a specified case load.

QUALIFICATIONS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

A. Experience, Education, Licensures & Certifications

• Required: Five years or more clinical and care management experience in hospital, home health/hospice, or managed care setting
• Required: Licensed Social Worker in the state of Ohio
• Preferred: Master’s degree in Social Work

B. Knowledge, Skills & Abilities

• Proficient in computer software and usage including but not limited to Microsoft Outlook and Microsoft Excel
• Knowledge of community resources and behavioral needs for adult population
• Knowledge of trends in healthcare, managed care, Medicaid, case management, medical management and quality improvement
• Demonstrate awareness and ability to work alongside diverse cultures and patient populations
• Ability to create positive working relationships with physicians and other members of the health care team
• Ability to demonstrate work toward the progress of patient- centered goals
• Ability to adapt to changing environment
• Ability to work independently and within a team environment with minimal supervision
• Excellent negotiation and advanced conflict resolution skills
• Strong analytical, organizational, and time management skills
• Strong written and verbal communication skills; ability to communicate effectively in stressful situations
• Self-disciplined, energetic, passionate, and innovative
• Decision making/problem solving and training/teaching skills
• Critical and ‘systems' thinker with strong attention to detail