• LSW Candidates:
  Base range: $57,720 – $72,280 annually
  Additional: +$1.25 per hour for Team Lead responsibilities
• RN Candidates:
  Base range: $66,040 – $76,128 annually
  Additional: +$1.25 per hour for Team Lead responsibilities

• Monitors progress towards required Care Management and Care Coordination activities for the County Care patient population in accordance with Medical Home Network policies.
• Works with Manager to oversees Care Management team and daily workflows, and provide or assign coverage within the team
• Assists with training and directing staff and interns to follow department workflows within specialty area (e.g. MHN Care Management and Care Coordination)
• Promotes teamwork and problem solves issues concerning patient care and completion of Care Management and Care Coordination tasks
• At the discretion of the Manager of Care Management, attend external meetings with community partners, third party payers including Medical Home Network, and external auditing bodies
• Maintain patient care hours per week at designated site as determined by Director of Care Management.
• Provide consultation and academic support to physicians in the areas of bio psychosocial care coordination that may affect overall health outcomes including social determinants of health, substance use and mental health concerns.
• Participate fully in relevant quality assurance and performance improvement measures.
• Provide comprehensive consultation regarding disease management assessment and mental/behavioral health treatment options to established patients.
  • Develop and execute an individualized care plan (may include medication reconciliation) for high-risk patients/family and other patients referred to you in collaboration with patient’s care team
  • Document data, assessment, care plan and expected outcome in electronic medical record.
  • Review and update care plan based on risk-determined calendar cycle (e.g. 30 days for high risk).
  • Maintain as near to, and no more than, a full case load as defined by manager and program requirements. Enroll new patients in a timely fashion per program requirements.
• Identify and follow-up on all referrals made to assure continuity of care and patient/family needs are met.
• Complete disease specific education as necessary with patient and patient family. For chronic conditions such as hypertension, DM, CHF/CAD, and stroke & rehabilitation, or SMI, CM conducts thorough assessment and education appropriate to scope of CM’s licensure with patient, including checks for understanding, appropriate SMART goal setting, and referrals to other sources for ongoing education as needed (including referrals to PCP, specialists, BH, collaboration with team RNs, group visits, medical education appointments).
• Complete home visits, or visits to skilled nursing facility or hospital as needed and determined by the care team.
• Perform any crisis intervention and advocacy that is needed for the patient. This includes telephone triage for patient’s presented routine, urgent, and emergent health concerns, and creating safety plans as needed.
• The CM-TL may also perform duties as assigned, such as

Experience:

• Masters Degree of Social Work or Bachelors in Nursing from an accredited University.
• 2 – 3 years clinical experience preferred.
• 2 - 3 years EMR experience preferred.
• Constantly communicates with patients, families, and other healthcare providers. Must be able to exchange accurate information in these situations.
• Demonstrated skills in the designated and certified clinical area of practice arena and the ability to work and collaborate on a health care team.
• Demonstrated ability to effectively and efficiently handle a demanding workload involving multiple tasks.
• Proficient in MS Office Business Application to include Outlook, Word, PowerPoint and Excel

Certifications/Licenses:

• Current and valid CPR certification.
• Either
  • Social Worker- LSW required
  • Nursing- RN required

Physical Demands:

• Must be able to remain in a stationary position 50% of the time.
• Must be able to move around the clinic site 50% of the time.
• Constantly operates a computer, computer printer, copy machine, and telephone.
• Occasionally positions self to maintain exertion of physical strength to move objects of 10 pounds from one level to another.
• Must be able to transport from one site to another.
• Must be able to cover other shifts as necessary.

Other Skills

• Ability to read and write proficiently using the English language.
• Constantly communicates with other healthcare providers. Must be able to exchange accurate information in these situations.
• Follow-through, assume responsibility and use good judgment.
• Maintain professionalism under stressful situations.
• Self-motivated and directed with the ability to prioritize and work efficiently under pressure.
• Ability to understand and follow verbal and written communication.
• Detail oriented with the ability to work with minimal/no supervision.
• Willingness to be part of a team-unit and cooperate in the accomplishment of departmental goals and objectives.
• Effective and creative problem solving.

Language Skills:

• Ability to read and write proficiently using the English language.
• Bilingual English/Spanish is preferred.