Community Based Health Manager, MSW, LSW

• Preferred - Behavioral Health and Geriatric experience. EPIC and Excel experience.

Onsite, Monday through Friday, no holiday or weekends.

Summary:
Responsible for the assessment, planning, implementation, monitoring and evaluation of case management services through the appropriate utilization of resources.

Application of appropriate medical necessity tools to maintain compliance and achieve cost effective and positive patient outcomes.

Utilizes independent critical thinking and decision making to formulate coordination of care and address patient’s individual plan of care and transition needs.

Position Responsibilities:
Assessment

• Conducts comprehensive assessments for assigned chronic disease high risk patients using a standardized tool
• Develops a patient centered individualized plan of care including treatment goals and addresses patient’s clinical, preventative screening, psychosocial and educational needs.

Care Coordination

• Coordinates appropriate care through clinical assessment and patient advocacy.
• Communicates and educates patient, family and healthcare team on the plan of care and transition options ensuring patient freedom of choice.
• Makes appropriate referrals within the scope of available benefits to facilitate a patient centered individualized plan of care.
• Facilitates appropriate services needed to meet needs of patient such as DME, HC, Meals on Wheels, transportation etc.

Quality

• Understands quality metrics and preventative screening associated with chronic disease management.

Communication

• Communicates effectively with physicians and care team the patient centered individual plan of care and assessment needs.
• Coaches the patient/care giver to meet patient centered individual plan of care goals.

Documentation

• Appropriate and complete documentation of assessments, patient centered individualized plan of care including treatment goals and patient/care giver education in patient record.
• Documents updates in treatment goals and preventative interventions in patient record.

Compliance

• Understands and applies applicable federal and state regulatory requirements
• Participates in organizational improvement activities, including patient satisfaction teams, six sigma teams, departmental/divisional teams, and community events.

Excellent verbal and written communication skills, problem solving, critical thinking and conflict resolution.

Preferred: 3 years clinical nursing (RN) experience and 1-year acute care UR/CM/QM experience or 3 years' experience as Clinical Social Worker in acute care.

Preferred: Behavioral Health and Geriatric experience.
EPIC and Excel experience.

Competent computer and technology experience.

Basic understanding of Medicare, Medicaid and managed care.

Required Education:
Graduate of an accredited School of Nursing or Graduate of an approved School of Social Work with a bachelor’s or master’s Degree.

Training/Certifications/Licensure:
Licensure and/or certification from the State of New Jersey as a Social Worker or Registered Nurse.