For members of a defined population, responsible for collaborating with the members of the health care team to facilitate the coordination of appropriate, cost-effective services that are consistent with members plan of care, help achieve his/her optimal level of independence, and enhance quality of life.

• Responsibilities include, but are not limited to, problem identification, psychosocial assessment, financial counseling/referral, accessing community resources, placement for care, guiding the member through health-related legal processes, or consultation and support to other health care professionals.
• Effectively manages and coordinates assigned caseload consistent with established criteria. Completes comprehensive psychosocial assessment to evaluate patient goals, social support systems, resources, health status, functional limitations, psychological status, environmental factors, and response to treatment so as to decrease inappropriate utilization of medical services.
• In close collaboration with the nurse case manager and other members of the health care team, develops and monitors a plan of care designed to promote the members optimal level of functioning and enhance the quality of life.
• Identifies, facilitates, and advocates appropriate organizational and community resources to meet the plan of care and ensures that they are implemented for in a cost effective, efficient, and timely manner.
• Ensures consistent and reliable documentation of case management activities in compliance with all organization and department standards.
• Analyzes patient and program outcomes to identify improvements in program, quality, and cost effectiveness of case management activities.
• Facilitates application process for accessing local, state, and federally funded programs (e.g., Medicaid, Medicare, and Disability) and/or refers to appropriate community agencies in cases of suspected patient abuse/neglect when identified.
• Provides supportive counseling and education to members, families and caregivers, members of the health care team, health plan staff, and the community, including end-of-life issues and Advanced Directives.
• Promotes self-awareness and knowledge of current case management standards in the community and recent innovations in patient care. Maintains current knowledge of laws, regulations, and policies relating to the practice of social work in the local market/local agencies and maintains high social work standards as defined by the NASW Code of Ethics.