Care Manager Community Based HEART Team

General Summary of Position

Job Summary:

Med Star Health is looking for a Care Manager Community Based to join our HEART Team! We are looking for a superior communicator, who shares information readily and concisely, while remaining solution focused and collaborative in nature with experience in coordination and collaboration with multiple providers and agencies, as well as comprehensive care plan development.

• Collaboratively develops care plans with HEART Team members and beneficiaries. Assists beneficiaries in developing their own goals. Documents beneficiary progress and treatment recommendations in medical records to be easily shared with primary care physicians, psychiatrists, and other providers.

• Facilitates team meetings for HEART Team members, beneficiaries, and primary care providers. Participates in regularly scheduled caseload consultation and communicates resulting treatment recommendations to the beneficiary and the beneficiary's care providers.

• Coordinates and monitors services, including comprehensive tracking of activities in relation to care plan. Designates the appropriate team staff so that specialized support and/or clinical expertise is applied as clinically indicated for each beneficiary. Provides brief interventions using evidence-based techniques such as Behavioral Activation, Problem‑Solving Treatment, and Motivational Interviewing.

• Manages risk factors of patients/families (e.g., legal, immigration status, language barriers, financial complications, employment, and disability). Determines required level and frequency of services. Provides supervision and guidance to Community Health Workers/Advocates regarding service implementation.

• Facilitates referrals for clinically indicated services outside the primary care clinic such as social services and housing assistance. In consultation with HEART Team, facilitates treatment plan changes for beneficiaries who are not improving as expected. Drives and travels to community locations, various agencies, and other outreach destinations. Participates in 24/7/365 on‑call rotation and coordinates after‑hours resources. Provides services remotely, in‑office, telephonically, via telehealth, in the community, or beneficiary's home as beneficiary needs and preferences dictate.

• Bachelor's degree in social work, Psychology, or Human Services.

• 3-4 years' experience with co‑occurring chronic medical and behavioral health conditions.

• Valid State Driver's License in good standing.

• CPR (Cardiac Pulmonary Resuscitation) within 90 Days.

• LCSW (License Clinical Social Worker) preferred.

• Master's degree in social work, Psychology, or Human Services preferred.

• One year of relevant professional-level work experience may be substituted for one year of required education.

This position has a hiring range of $59,820 - $101,836