The Care Manager is responsible for the provision of professional medical care coordination services to patients and their families in our Health Home program, and provides medical care coordination consultation to patients in compliance with applicable laws, regulations, and Agency policies.
Establishes and maintains effective working relationships with patients, families, agency staff and other community agencies.
Gathers pertinent medical and non-medical information from patient/family/staff or from patient record on referred patients.
Assesses the environment of the home and community to identify elements which impact negatively on the patient's/family's ability to function.
Develops a plan of care in collaboration with the patient, family and other health professionals.
Provide direct medical care coordination services to patient/family or makes appropriate community/health referrals.
Conducts comprehensive assessment with clients and/or their affected family members in a timely manners.
Attends training seminars, staff meetings and supervision on a regular basis and in a prompt manner.
Helps patients and families to develop capabilities that permit them to make optimum use of health and social facilities.
Participates in conferencing and planning with other disciplines caring for the patient.
Maintains documentation of progress notes, plan of care, and other forms in a timely manner in compliance and regulations.
Performs all other related duties, as required.
Participates in performance improvement activities.
Participates in evaluating overall position performance, goal setting and achievement, and performance improvement plan.
A Bachelor's degree in social work, psychology, child and family studies, anthropology, sociology, and other degrees pertaining to the social sciences, human services and/or public health field
Preferred minimum of 2 years social work experience in health care/social work setting as a member of a multidisciplinary team.
Bilingual required (Spanish/English)