Care Manager – Social Worker/RN

Written by spartanburg - - Comments Off on Care Manager – Social Worker/RN
Spartanburg Regional Medical Center
Published
October 19, 2021
Location
Spartanburg, South Carolina
Job Type

Description

Care Manager - Social Worker/RN

  • Spartanburg, SC
  • Grants Administration
  • Health Management Network
  • Full-Time - Days (weekends as needed) - 8:30a-5:00p
  • Professional/Technical
  • Job Grade E10
  • Req #: 42457

Summary

The Care Manager is assigned a panel of patients to manage in collaboration with primary care providers and members of the care management team. The Care Manager will educate the patients on self-care, properly accessing healthcare services, and will utilize motivational interviewing techniques.  The Care Manager is also responsible for coordinating care and community services to obtain desired health outcomes, decrease cost of care, improve quality of life, and provide extraordinary patient care in the process. The Care Manager utilizes evidence-based medicine, data analytics and innovation in implementing care management principles to meet patients’ and their families' needs.  Additionally, the Care Manager must be flexible and adapt to changes in the work environment, manage competing demands, change the approach/method to best fit the situation and be able to cope with delay or unexpected events. It is essential to take responsibility, keep commitments and complete tasks on time. Also, volunteer readily, take independent actions and ask for and offer help when needed.

 

Minimum Requirements

Education

  • RN, or Licensed Clinical Social Worker, or equivalent

Experience

  • 5 years of experience in outpatient setting, population health, social services, home health, or other healthcare setting.

License/Registration/Certifications       

  • Valid Driver’s license with good driving record

 

Preferred Requirements

Preferred Education

  • Bachelor’s Degree

Preferred Experience

  • Care management experience

Preferred License/Registration/Certifications   

  • N/A

 

 

Core Job Responsibilities

 

  • Provide telephonic or face to face outreach to engage members to assess their readiness to change by using motivational interviewing techniques to help members identify and overcome barriers that often include behavioral risk factors, such as smoking, poor health literacy, sedentary lifestyle, elevated BMI, and poor disease management.
  • Coordination of referrals and transitions of care from one provider to another or from one care setting to another.
  • Provide medication adherence education with patients and family members.
  • Facilitation and/or procuring timely access to appointments and services required by patient
  • Patient and Family/Caregiver education.
  • Perform facility visits, not limited to; inpatient, home, office/clinic, SNF/Rehab, within a designated time frame.
  • Evaluation of effectiveness of care plan with Complex Case Review as Requested
  • Evaluates baseline medical and psychosocial evaluations with patient and creates individualized patient care/treatment plans in conjunction with care transition coaches, senior care coordinators, and partners with primary care and specialties.
  • Assesses patient and patient's family on ability to self-engage and develops individualized patient and patient's family education plan focused on development of self-management skills based on RHP standard of care protocols.
  • Identifies patients with special needs and facilitates integration of primary care with specialty and other services such as behavioral, social and community services where appropriate.
  • Plans, develops, assesses, and evaluates care provided to specific patient populations, and engages team of care transition coach and care coordination to divide workload among team where appropriate.
  • Performs analysis of the effectiveness and appropriateness of patient care plan; and modifies care plan based on assessment and evaluation.
  • Communicates clear, complete and accurate documentation in a health record to ensure that all those involved in a client's care have access to necessary information to plan and evaluate their interventions.
  • Updates plan of care to ensure all care team members have timely information regarding the patient's status.
  • Ensure the proper handling of patient records to ensure compliance with patient health information applicable to the preservation, accuracy, and completeness of communication and/or retention of patient information, meeting all HIPAA regulations and the HITECH Act provisions as required by law
  • Must meet productivity standards set for by direct supervisor.
  • All other duties as assigned
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