Primary Duties and Responsibilities

The Care Manager (RN/MSW) coordinate patients’ needs through the continuum of care which can include from pre-admission through post discharge plans. This role works in collaboration with the physicians, nurses, clinical staff, and community agencies to identify and arrange for appropriate care.

Reviews clinician assessments and patients’ financial, family and psychosocial support to develop comprehensive care and/or discharge plans. May focus more heavily on a specific aspect of Care Management like discharge planning, utilization review, and/or providing psychosocial support.

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. Educates patients and families on their healthcare options and connects them with resources.

Documents pertinent patient issues, contacts and plans on the medical records. Is a mandated reporter for elder, child, and spousal abuse. The Community Care role specifically provides Care Management support to high-risk, homeless and mental health population. Performs other duties as assigned.

Community Health: The Care Manager/ Social Worker (MSW) 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 patients' needs including financial, family and psychosocial support, and develops tailored care plans.

Records client progress including referrals, home visits, and other notable interactions; periodically evaluate client’s progress and adjusts to improve outcomes. Collaborates with the Center for Healthy Living staff, 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. Performs other duties as assigned.