CARE MANAGER-SOCIAL WORK (REMOTE)
Responsible for overall care management and quality of care for participants. Uses specialized discipline-specific knowledge to review assessments of field staff and coordinate a holistic care plan that addresses all domains of care.
Job Title: Care Manager – Social Work
JOB PURPOSE:
Responsible for overall care management and quality of care for participants.
Uses specialized discipline-specific knowledge to review assessments of field
staff and coordinate a holistic care plan that addresses all domains of care.
Provides care coordination in a manner that is sensitive to age, gender, sexual
orientation, cultural, linguistic, racial, ethnic, religious backgrounds, and
congenital or acquired disabilities.
JOB RESPONSIBILITIES:
- Participates and represents the individual’s discipline in the care planning
meetings or as necessary.
- The Care Manager will review all discipline-specific documentation for
quality and addresses any deficiencies with the field staff following
disciplinary steps established by the Discipline Policy.
- Monitor how field staff is documenting all interventions with the
participants and address/document any issue observed with the
employee.
- Conduct coaching sessions with field staff as needed.
- The Care Manager (CM) communicates with the discipline-specific field
staff regularly to coordinate a continuum of care consistent with the
Member’s health care needs and goals. This care plan supports the
Member in attaining and maintaining an optimal functional and health
status.
JOB DESCRIPTION
provisions of appropriate services to meet identified member-specific
needs (such as assistance with the Activities of Daily Living (ADLs) and
Instrumental Activities of Daily Living (IADLs), housing, home-delivered
meals, and transportation) and when approved by the IDT, may authorize
a range and number of community-based services.
- Implements specific care management activities and interventions that
lead to accomplishing the participant’s goals.
- Provides care management services across sites and collaborates with
appropriate team members, facility, discharge planner, and home care
coordinator when members are transitioned between care settings.
- Documents services in accordance with CenterLight standards and
federal/state regulations
- Coordinates, facilitates, and arranges for long-term care services in
nursing homes, rehab facilities, etc. as needed.
- Collaborates with PCP and other Specialty physicians and specialtybased
services and members of IDT regarding any changes in
participant’s condition to secure, arrange and coordinate all resources for
implementing optimal care.
- Provides or arranges for ongoing Skilled services, service authorization,
and periodic assessment reassessment and evaluation of services.
- Monitors care management activities, services, and members’ responses
to interventions, to determine the effectiveness of the plan of care and
the utilization of services and implements changes and adjustments to
meet needs and resolve goals.
- Evaluates the effectiveness of the plan of care in reaching desired goals
and outcomes, makes modifications or changes in the plan of care based
on changes in the member’s health, as needed.
- Fiscally responsible for providing services based on members’ needs.
- Maintains up-to-date knowledge about current health-related issues,
procedures, evidence-based clinical practice guidelines, medications,
and impacting health and practice standards.
- Conduct competencies, and training sessions with field staff as needed.
- Recommends and contributes to improvements in services, programs,
policies, and procedures to ensure optimum care and services to
members.
- Follows the organization’s policies regarding disciplinary action. Engages
Human Resources as needed for guidance on disciplinary actions and
terminations.
- Only act within the scope of the individual’s authority to practice.
- Meet a standardized set of competencies for the specific position
description established by the PACE organization before working
independently.
- Acting member of the IDT.
- All other duties as assigned.
QUALIFICATIONS:
Education: Graduated from a Master Social Work program acceptable to New
York State Education Department (NYSED.)
Experience:
- Minimum of two (2) years of administrative experience in a management
capacity in a certified home health agency (CHHA), Manage Care, longterm
home health care (LHCSA), acute care, medical-surgical, and/or
critical care, nursing home experience, diagnostic & treatment clinic
preferred.
- Customer Service experience required.
- Managed long-term care insurance experience beneficial.
- Minimum of one (1) year of experience working with a frail or elderly
population or, if the individual has less than one (1) year of experience but
meets all other requirements, must receive appropriate training from the
PACE organization on working with a frail or elderly population upon
hiring.
- Supervisory experience preferred.
Additional Requirements:
- Be legally authorized (for example, currently licensed, registered, or
certified if applicable) to practice in the State in which the healthcare
professional will perform the function.
- Be medically cleared for communicable diseases and have all
immunizations up-to-date before engaging in direct participant contact.
License: Current active and unrestricted license and registration in New York
State required.
Language: Bilingual, preferred.