This position is community-based with responsibilities within both EmblemHealth Neighborhood Care and EmblemHealth’s care management regional teams. The Social Work Case Manager is a specialist who provides case management services for the chronically ill or at-risk population with an overall objective to help member’s live fuller and more meaningful lives. The Social Work Case Manager will assist in managing members with behavioral health, substance abuse, and/or psychosocial conditions/issues, consulting with colleagues across the enterprise. on behavioral health, substance abuse, and/or psychosocial issues. As a behavioral health specialist, the Social Work Case Manager facilitates member adoption of strategies to promote physician recommended behavior changes. Social Work Case Managers will help members improve health outcomes and provide feedback to members of the medical and care management care teams.
- Perform member outreach – telephonically and in-person, individual needs assessment, education on early warning signs of disease and disease prevention, and identifying customers in potential need of care. Support services as well as social service supports from other organizations (community based and otherwise).
- Responsible for managing a caseload of members with behavioral health diagnoses and serving as a consult resource for the integrated care team for all members with co-morbidities to support activities with interdisciplinary care team, ie. Care Specialist, Care Manager, within Regional Model of Care
- Work within interdisciplinary team of Care Specialists and Care Managers to complete health assessments and individualized Care plans
- Assists members with the coordination of services from various settings as appropriate, includes facilitating discharge from acute setting to home and acute setting to alternate settings. Provides Care Coordination throughout the continuum of care by including the member, member’s family and providers in the process.
- Assesses members Social Determinants of Health, such as housing, food, transportation and safety in the home and assesses members Mental health needs including PHQ2 and 9 Depression screening, Provides referrals for mental health counseling .- Provides additional appropriate referrals and support as needed.
- Support activities of other Neighborhood Care team members
- Participate in all other projects relating to community clinical programming as identified by Regional Manager, Director and AVP in Neighborhood Care,, Care Management and Medical Management Leaders.