LCSW Care Manager

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• Responsible for patient outreach, assessment, disease management, and care coordination to patients with high rates of medical and behavioral health utilization and/or psychosocial vulnerability
• Assess patients through telephonic and eventually face to face encounters
• Builds a collaborative relationship with patients and their identified support system to encourage care participation and improve self-management of needs
• Utilize motivational interviewing to identify barriers and facilitate care plan compliance
• Effectively educate patients about healthcare delivery, plan benefits and a variety of topics related to health, and community resources
• Coordinates timely and appropriate implementation of assessments, care plans, and interventions for the identified patient population
• Provide medication reconciliation and support ongoing adherence
• Identify and helps to align patient care and community resources to prevent hospital readmissions and Emergency Department visits
• Document all activity in the documentation systems relevant to the role
• Collaborate with the care team to achieve high-quality, low-cost outcomes for patients.
• Interface and maintain positive relationships with key providers in the local hospitals, community practices, and organizations to ensure proper patient engagement and follow up
• Achieve established productivity targets
• Maintain compliance with the organization policies and procedures
• Demonstrate the ability to adapt, innovate and lead in a fast-paced environment, where change is common
• Passionate about making a difference in individual’s lives
• Other duties as assigned

• Responsible for patient outreach, assessment, disease management, and care coordination to patients with high rates of medical and behavioral health utilization and/or psychosocial vulnerability
• Assess patients through telephonic and eventually face to face encounters
• Builds a collaborative relationship with patients and their identified support system to encourage care participation and improve self-management of needs
• Utilize motivational interviewing to identify barriers and facilitate care plan compliance
• Effectively educate patients about healthcare delivery, plan benefits and a variety of topics related to health, and community resources
• Coordinates timely and appropriate implementation of assessments, care plans, and interventions for the identified patient population
• Provide medication reconciliation and support ongoing adherence
• Provide transitional care management
• Identify and helps to align patient care and community resources to prevent hospital readmissions and Emergency Department visits
• Document all activity in the documentation systems relevant to the role
• Collaborate with the care team to achieve high-quality, low-cost outcomes for patients.
• Interface and maintain positive relationships with key providers in the local hospitals, community practices, and organizations to ensure proper patient engagement and follow up
• Achieve established productivity targets
• Maintain compliance with the organization policies and procedures
• Demonstrate the ability to adapt, innovate and lead in a fast-paced environment, where change is common
• Passionate about making a difference in individual’s lives
• Other duties as assigned

• Requires a Master’s in Social Work
• Must have a current full licensure as a LCSW by the NC Social work Certification and Licensure Board
• Two years post master’s clinical experience is required
• Medical Social Work experience strongly preferred
• Knowledge of care management and quality principles are preferred
• Requires the ability to maintain confidentiality
• Must be able to interact with individuals of all cultures and level of authority

• Excellent and effective written and oral communication skills.
• Proficiency in Microsoft Office Outlook, Word, Excel, PowerPoint use and e‐mail communication.
• Abil…