Overview
Case Manager, licensed clinical social worker is assigned a case load of Medicare beneficiaries with multiple chronic conditions and complex care needs. The case manager coordinates services and care plans with the Medicare beneficiary and family care givers, including developing clinical care and preventive care strategies. Assesses and addresses SDOH and behavioral or mental health risk factors. Position also will direct community health workers who perform home safety, health, and SDOH risk assessment with the Medicare beneficiary.
Position will work predominantly in the Southern Region of Arizona, including Pinal, Pima, Cochise, Greenlee and Yuma counties. Much of the case management is handled over the phone or via web conference, however, some home visits may be necessary. Candidates must reside in southern Arizona.
Responsibilities

• Works one-on-one with individuals to help them solve problems and deal with challenges associated with health and behavioral health issues and Social Determinants of Health.

• Meets with Medicare beneficiaries to assess their histories, conditions and needs.

• Provides short-term counseling and engages in advocacy work with local, state, and federal agencies and non-profit community service organizations to service referrals and follow up.
• Interviews and counsels Medicare beneficiaries to assess functional status risk factors and develops an individual care plan including recommending service referrals and medical or behavioral health assessments.

• Collaborate and communicates with the PCP, other members of the primary care team, community workers and ABC Network team to coordinate case planning and management as well as those related to managing Medicare beneficiary services, assessments, home visits, health education, and family caregiver support.

• Assures that the Medicare beneficiary gets follow up care with PCP after ER visit and transition of care between hospital and home or skill nursing and home as well as is receiving timely and appropriate care for various chronic conditions.
• Provide end of life support and guidance for Medicare beneficiaries, caregivers and their families and assist with transition of care from Skilled Nursing Facility to hospice or home.
• Evaluates and recommends a course of action related to behavioral issues, mental health and emotional disorders.

Qualifications

• Master’s degree in clinical social work, psychology, sociology or similar field.
• Experience of 3 – 5 years in case management of patients with complex care needs and social determinants of health risk factors.
• Knowledge of behavioral counseling, assessment of patient risk, and therapies

• Ability to manage and coordinate care for high risk and culturally diverse Medicare beneficiaries living in rural areas of Arizona.

• Evidence-based practice related to depression management, dementia, and other mental disorders.
• Requires expertise utilizing analytic EHR, excel spreadsheet and case management software.
• Position requires critical thinking and strong problem-solving skills.

Other Requirements

• Arizona Driver’s License
• Must be a Permanent Arizona resident.
• Bi-lingual in Spanish desirable
• Travel is required, must have a car.
• Frequently required to stand and walk.
• Frequently required to sit and work at a computer.

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