Community Care Manager - SW - MDPCP
Luminis HealthAnnapolis, Maryland, United States · Posted 5 days agoDescription
Position Objective
Endowed with clinical knowledge and experience, the Maryland Primary Care Program (MDPCP) Community Care Manager- SW works collaboratively with physicians, staff, and other health care professionals to provide care coordination and ensure that safety, best practices, and high quality standards are maintained across the continuum. S/he maintains knowledge of care management, behavioral health, social determinants of health, and chronic disease self-management resources available to patients and facilitates patients' adoption of supportive services. S/he plays an integral role in promoting access to appropriate community care resources, including transitional care services for vulnerable patients recently discharged from the hospital or ED, and providing care management to high-risk patients. S/he maintains access to and proficiency in programs including Epic, patient registries, and CRISP. Success will be measured by performance results at the practice and population levels.
Essential Job Duties
- Function as team subject matter expert in identifying the social determinants of heath and the optimal community resources to support high and rising risk patients in the self-care management.
- Assist patients through healthcare continuum as a patient advocate, navigator, and liaison to team, providers and/or community resources.
- Provide leadership to the team to improve care, community resource coordination, and manage the referral processes.
- Facilitate health and disease patient education and support patient self-management of disease and behavior modification interventions.
- Collaborate with patients, care team, and providers to understand patient short and long-term goals and contribute to patient longitudinal plan of care.
- Coordinate continuity of patient care with providers across the healthcare system, including post-hospital or ED discharge.
- Use high-risk screening criteria to identify and manage high-risk patients, including patients with multiple comorbidities or are at risk of avoidable utilization/readmission.
- Participate on teams for data collection, health outcomes reporting, clinical audits, and programmatic evaluations related to the Maryland Primary Care Program (MDPCP), and quality improvement initiatives.
- Evaluate the psycho-social clinical plan of care, resource utilization, and contribute to the development of new tools, forms, and procedures.
- Contribute to the performance evaluation of team members.
Educational/Experience Requirements
- Master's degree with a focus in social work. LCSW – C required (or obtained within 6 months of employment)
- At least 5 years of experience in healthcare with care management experience.
Required License/Certifications
- Required License/Certification: Licensed Certified Social Worker (LCSW) or Licensed Certified Social Worker Clinical (LCSW-C) from the Maryland Board of Social Work Examiners or other approved designated Social Worker license/certification. If Licensed Certified Social Worker (LCSW), must obtain Licensed Certified Social Worker Clinical (LCSW-C) within 6 months of hire.
- Current American Health Association Health Care Provider Basic Life Support (BLS) CPR certification.
- Case Management Certification strongly preferred.
Working Conditions, Equipment, Physical Demands
There is a reasonable expectation that employees in this position will not be exposed to blood-borne pathogens.
Physical Demands – Light Duty
The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.
The above job description is an overview of the functions and requirements for this position. This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.
Luminis Health Benefits Overview
- Medical, Dental, and Vision Insurance
- Retirement Plan (with employer match for employees who work more than 1000 hours in a calendar year)
- Paid Time Off
- Tuition Assistance Benefits
- Employee Referral Bonus Program
- Paid Holidays, Disability, and Life/AD&D for full-time employees
- Wellness Programs
- Employee Assistance Programs and more
*Benefit offerings based on employment status
Pay Range
$33.55 — $50.33 USD per hour
Opt-in for text notifications!
Luminis Health's two-way SMS texting platform lets you receive notifications and messages from our Talent Acquisition team directly on your phone.
To enable this feature, select "yes" when asked to "opt-in to receive text messages" and to "Receive updates from a recruiter about this job via SMS" when completing your application. Once you are opted in, you can easily opt-out at any time.
Standard text messaging rates may apply based on the candidate's mobile carrier plan. Luminis Health is not responsible for any charges incurred by the recipient. Candidates are encouraged to review their mobile carrier's plan for applicable text messaging rates and usage charges.
Similar jobs
Est. 88,400 USD
Position ObjectiveThe Case Manager works under the direction of the clinical director of care management, providing coordination of care for patients at Luminis Health to support safe, seamless, timely transitions across…
Est. 88,400 USD
Position ObjectiveThe Case Manager works under the direction of the clinical director of care management, providing coordination of care for patients at Luminis Health to support safe, seamless, timely transitions across…
Est. 90,000 USD
Position ObjectiveThe Licensed Clinician will work in tandem with the primary care team and is responsible for providing brief intervention and consultation to patients in an outpatient setting. Services to include: cris…
Est. 88,400 USD
Position ObjectiveThe Case Manager works under the direction of the clinical director of care management, providing coordination of care for patients at Luminis Health to support safe, seamless, timely transitions across…
Est. 88,400 USD
Position ObjectiveThe Case Manager works under the direction of the clinical director of care management, providing coordination of care for patients at Luminis Health to support safe, seamless, timely transitions across…
Est. 90,000 USD
Position ObjectiveThe Licensed Clinician will work in tandem with the primary care team and is responsible for providing brief intervention and consultation to patients in an outpatient setting. Services to include: cris…
Est. 88,400 USD
Position ObjectiveThe Case Manager works under the direction of the clinical director of care management, providing coordination of care for patients at Luminis Health to support safe, seamless, timely transitions across…
Est. 90,000 USD
Position ObjectiveThe Licensed Clinician will work in tandem with the primary care team and is responsible for providing brief intervention and consultation to patients in an outpatient setting. Services to include: cris…
Est. 47,840 USD
Position Objective:Care Management Assistants are administrative professionals who provide direct support to ensure that patients move through the system and receive the treatment and services they require. They are resp…
Est. 83,200 USD
Position ObjectiveProvides counseling, crisis intervention, and transition planning services to AAMC patients of all ages and their families. Performs psychosocial assessments, plans for and implements identified service…
Est. 83,200 USD
Position ObjectiveProvides counseling, crisis intervention, and transition planning services to AAMC patients of all ages and their families. Performs psychosocial assessments, plans for and implements identified service…
Est. 100,100 USD
Position ObjectiveProvides psychosocial assessment, individual, family and group therapy to case load of patients. Assessments, plans for and implements identified services for patients. Works with the patient and family…
Est. 100,880 USD
Position ObjectiveContributes to the provision of high-quality, cost-effective healthcare as a provider of direct and indirect patient care and by effective of the health care team. Functions as a competent member of the…
Est. 83,200 USD
Position ObjectiveProvides counseling, crisis intervention, and transition planning services to AAMC patients of all ages and their families. Performs psychosocial assessments, plans for and implements identified service…
Est. 104,000 USD
Position ObjectiveContributes to the provision of high-quality, cost-effective healthcare as a provider of direct and indirect patient care and by effective collaboration with the health care team. Functions as a compete…
Est. 48,651 USD
Position Objective:Advanced Medical AssistantThe Advanced Medical Assistant is an essential part of the Advanced Primary Care Team and facilitates meeting the goals of the Maryland Primary Care Program and Value Based Co…
Est. 83,200 USD
Position ObjectiveProvides counseling, crisis intervention, and transition planning services to AAMC patients of all ages and their families. Performs psychosocial assessments, plans for and implements identified service…
Est. 88,400 USD
Position ObjectiveProvides expert direct care to patients, families and family systems; provides teaching, evaluation, assessment and counseling to patients and families as needed.Essential Job DutiesReasonable accommoda…
Est. 43,680 USD
Position ObjectiveTo provide supervised medical services for patients with emphasis on acute/same day care. All duties are in collaboration with contracted physician; services are provided under the rules, regulations, a…
Est. 43,680 USD
Position ObjectiveTo provide supervised medical services for patients with emphasis on acute/same day care. All duties are in collaboration with contracted physician; services are provided under the rules, regulations, a…
Est. 43,680 USD
Position ObjectiveTo provide total medical care/services to patients as related to their specialty. Services are provided in accordance with the rules, regulations, and policies established by the job descriptions of the…
Est. 50,310 USD
Position ObjectiveResponsible for the day-to-day administration of the hospitalist program for more than one practice. Serve as the liaison between the Practice Manager, Hospitalist Supervisor of the program, individual…
Est. 43,680 USD
Position ObjectiveTo provide total medical care/services to patients as related to their specialty. Services are provided in accordance with the rules, regulations, and policies established by the job descriptions of the…
Est. 43,680 USD
Position ObjectiveTo provide supervised medical services for patients with emphasis on acute/same day care. All duties are in collaboration with contracted physician; services are provided under the rules, regulations, a…
Est. 131,000 USD
Position ObjectiveDirects overall operational functions for assigned areas.Essential Job DutiesReasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Reports to…
Est. 47,840 USD
Position ObjectiveMedical Assistants perform a variety of administrative and clinical tasks to help provide care to patients, support providers, and keep office operations running smoothly.Essential Job DutiesReasonable…
Est. 104,000 USD
Position ObjectivePromotes the delivery of high-quality, cost-effective health care through the provision of expert clinical education. Collaborates with the leadership team in the planning and implementation of organiza…
Est. 131,000 USD
Position ObjectiveDirects overall operational functions for assigned areas.Essential Job DutiesReasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Reports to…
Est. 110,000 USD
Position ObjectiveTo promote the delivery of high quality, cost-effective health care through the provision of expert clinical staff education and professional development. Collaborates with the leadership team, clinical…
Est. 115,000 USD
Position ObjectiveTo provide supervised medical services for patients with emphasis on acute/same day care. All duties are in collaboration with contracted physician; services are provided under the rules, regulations, a…