Provides care management through a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet member's health needs through communication and available resources, while promoting quality cost-effective outcomes. Maintains members in the most independent living situation possible; ensures consistent care along entire health care continuum by assessing and closely monitoring members' needs and status. Provides care management services and authorizes/ coordinates services within a capitated managed care system. Communicates and collaborates with primary care practitioners, interdisciplinary team and family members.

$70,200.00 - $87,700.00 Annual

What We Provide

What You Will Do

• Assesses, plans and provides intensive and continuous care management across acute, home, and long-term care settings. Develops and negotiates care plans with members, families and physicians.
• Assesses a person's living condition/situation, cultural influences, and functioning to identify the individual's needs; develops a comprehensive care plan that addresses those needs.
• Assesses an enrollee's eligibility for Program services based on his or her health, medical, financial, legal and psychosocial status, initially and on an ongoing basis.
• Plans specific objectives, goals and actions designed to meet the member's needs as identified in the assessment process that are action-oriented, time-specific and cost effective.
• Implements specific care management activities and or interventions that lead to accomplishing the goals set forth in the plan of care.
• Coordinates, facilitates and arranges for long term care services in the home and community-based sites, such as adult day care, nursing homes, rehab facilities, etc. Arranges for on-going nursing care, service authorization and periodic assessment.
• Collaborates and negotiates with interdisciplinary teams, health care providers, family members, and third-party payors, as applicable, across all health settings to ensure optimum delivery and coordination of services to members.
• Monitors care management activities, services, and members' responses to interventions, to determine the effectiveness of the plan of care and the utilization of services.
• Evaluates the effectiveness of the plan of care in reaching desired outcomes and goals; makes modifications or changes in the plan of care as needed.
• Identifies trends and needs of groups in the community and plans interventions based on these identified needs.
• Provides care management services across sites and collaborates with appropriate facility discharge planner and/or HCC when members are transitioned between settings.
• Manages expenditures to ensure effective use of covered services within a capitated rate. Fiscally responsible in providing services based on members' needs.
• Provides social work services in accordance with NASW code of ethics, VNS Health policies, practices, and procedures.
• Participates in outreach activities to promote knowledge of the Program and its services and to coordinate Program activities with outside community agencies and health care providers (e.g., community health screening, In Services).
• Participates in the development of programs to meet the specialized needs of this selected patient population.
• Documents services in accordance with Health Plans Community Care standards and Managed Long Term Care (MLTC) and Licensed Home Care Services Agency (LHCSA) regulations.

For Palliative Care Only:

• Understands and supports ability to cope with patients' illness. Provides emotional, spiritual, and practical support for patient and family.
• Reviews tools, programs and other resources for potential serious illness program appropriate patients and make referral as necessary.
• Provides education to patients and their families to better understand patients' disease and diagnosis.
• Facilitates open discussion about treatment choices for patient's illness (including difficult and complex choices) and management of symptoms.
• Provides expertise in treatment of pain and other symptoms.
• Participates in special projects and performs other duties as assigned.

Licenses and Certifications:

• License and current registration to practice as a Licensed Social Worker in New York State preferred

Education:

• Master's Degree in Social Work required
• Case Management Certification preferred

Work Experience:

• Minimum of three years of Social Work experience required
• Minimum of two years in a case management and/or community-based environment preferred
• Bilingual skills may be required, as determined by operational needs.
• Clinical expertise in geriatrics, Long Term care and Managed care experience preferred