Social Worker; TOC *Hagerstown

Overview

This position will be doing home and facility visits in Hagerstown 4-5 days/week.

The Social Worker will support the Transition of Care (ToC) Team with the management of difficult social needs at discharge for identified high-risk complex members to allow for continuity of care starting in the facility setting and allow for appropriate transition of care. In this role, the Social Worker will contact the Facility Case Manager and the Member while in the Hospital or a Skilled Nursing setting and begin to facilitate the discharge to the next appropriate level of care.

The Social Worker will work directly with Facility Case Managers and MPC members to address social barriers and provide care management through a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet members’ health needs through communication and available resources, while promoting quality cost-effective outcomes. The social worker will assist MPC Members to transition to the most independent living situation possible;

ensures consistent care along the entire health care continuum by assessing and closely monitoring members’ needs and status.

Maryland Care Management, Inc. (MCMI) manages Maryland Physician Care's (MPC) statewide provider network of hospitals and physicians. Maryland Physicians Care has been providing services to the Health Choice Medicaid populations since 1996, and we are proud of our footprint in the community. With over 230,000 members, MPC consistently has been one of MD s largest Medicaid-managed care organizations.

MCMI recognizes the importance of flexibility and offers multiple work arrangements. Along with competitive pay, we offer excellent benefits (medical, dental, and vision plans, 100% employer Term Life Insurance, Short and Long-Term Disability, 401k Employer Match up to 4%) as well as 20 days of PTO, and tuition assistance/professional development plans. Your future colleagues at MCMI are welcoming, friendly, and eager to help each other succeed.

We are committed to Diversity, Equity, and Inclusion, providing organizational-wide social opportunities, and constantly improving our ongoing efforts to positively impact our members  lives.

• Evaluate members based on their needs and limitations based on referrals.
• Will work directly with the Hospital/SNF case management staff to assist with the coordination of care and discharge plans for identified members.
• Will collaborate directly with members and their families to build a rapport to assist with discharge needs as appropriate.
• Address member concerns and goals while maintaining constant communication with the member.
• Utilizes clinical judgement to assess members, prioritizing emerging issues to maintain a member-centric approach.
• Collaborates with interdisciplinary care team at the facilities to support member health goals via conference calls, rounds, and consultation, which may include face-to-face meetings.
• Complete assessments to better understand the Social Determinants of health and social issues impacting member care goals.
• Utilizes problem-solving skills to research and identify community resources and coordinate a referral mechanism.
• Plans specific objectives, goals, and actions designed to meet the members’ needs as identified in the assessment process that are action-oriented, time-specific, and cost-effective.
• Implements specific activities and/or interventions that lead to accomplishing the goals outlined in the plan of care.
• Develop trusting relationships with members by providing support and advocacy to help achieve health goals.
• Monitors care management activities, services, and members’ responses to interventions, to determine the effectiveness of the plan of care and the utilization of services.
• Evaluate the effectiveness of the plan of care in reaching desired outcomes and goals; makes modifications or changes in the plan of care as needed.
• Make connections with members through visits to the hospital, home, and community via face-to-face, telephonic and/or video conferencing.
• Participates in…