Primary Duties and Responsibilities

The Care Manager (RN/MSW) utilizes clinical expertise, patient assessments, and insurance payer requirements to coordinate patients’ needs through the continuum of care including post-acute care and discharge plans. This role works in collaboration with the physicians, nurses, clinical staff, and community agencies to identify and arrange for appropriate care. Resource utilization is considered when coordinating the patients’ needs through the continuum of care. May focus more heavily on a specific aspect of Care Management like discharge planning, utilization review, and/or providing psychosocial support. May review clinician assessments and patients’ financial, family and psychosocial support to develop comprehensive discharge plans. May review records to assess for appropriate admission status, level of care, payer source, and UR contracts to validate billing. May provide psychodynamic intervention and crisis counseling to support patients and families. May educate patients and families on their healthcare options and connect them with resources. Documents pertinent patient issues, contacts and discharge plans on the medical records. Is a mandated reporter for elder, child, and spousal abuse. Performs other duties as assigned.

In additional to the above, the Care Manager II (LCSW) trains and mentors new staff. If in a Magnet facility, participates in Magnet councils and act as a preceptor in the Nurse Care Manager intern program.

Neuro Administration Department

The Care Manager II will provide care in the outpatient environment. In addition to the above, the Care Manager in Neuro will also focus heavily on a specific aspect of care management like disability paperwork and coordination.

Community Health

The Care Manager/ Social Worker II (LCSW) provides care in the outpatient environment and surrounding community as dictated by Community Benefit parameters. Coordinates and provides care that is safe, timely, effective, efficient, equitable, and client centered. Manages the client needs through the continuum of care which can include intake through case termination plans. Assesses patient’s needs including financial, family, and psychosocial support and will develop tailored care plans. Record client’s progress including referrals, home visits and other notable interactions; periodically evaluates client’s progress and makes adjustments to improve outcomes. Collaborates with the Center for Healthy Living staff, and partner agencies, and other community agencies as needed. Provides care to higher acuity patients and works with team members to arrange for appropriate resources. May provide psychodynamic intervention and crisis counseling to support clients. Facilitates psychoeducational groups as needed. Assists in training interns, collecting data to measure program outcomes. Partners with program supervisors to plan and coordinate community education and awareness events, outreach, using cross cultural competence to ensure the needs of stakeholders are met. Focuses heavily on a specific aspect of care management as directed by Community Benefit priority areas/needs assessment. Provides training and clinical supervision to pre-licensed staff as needed. Performs other duties as assigned.