Social Worker II - CMHRP

Primary Purpose of Position To provide the delivery of pregnancy care management services that improve birth outcomes in the North Carolina Medicaid population and thereby reduce costs. The pregnancy care managers, working with DHB network, provide a variety of services in the form of population management and direct pregnancy care management. Work Schedule Monday through Friday, 8:00 am – 5:00 pm. If the maternity clinic is in operation after hours at the Health Department, the employee will rotate with CMHRP staff to cover staffing for Social Work services. The Social Worker may have to work emergency shelter or special clinics as necessary. Responsibilities Utilize targeted data and referrals to identify pregnant and postpartum women who may benefit from pregnancy care management. Engage pregnant and postpartum women with priority risks and complete clear documentation of pregnancy assessment, conditions/needs, interventions, goals and other pregnancy care management activities in Virtual Health. Recruit and initiate referrals from multiple sources (initial risk screening forms, hospitals, community agencies, self‑referral). Maintain ongoing contact with local physicians and community agencies that provide medical care and services to pregnant and postpartum women in order to promote referrals for care management. Serve as the Care Manager for Medicaid‑eligible pregnant and postpartum women residing in Nash County, following State DHB, PHP and DHHS guidelines, performing at least the following activities: Outreach, population identification, assessment and risk stratification. Interventions based on plan of care and referrals as indicated. Integration with health care providers (Medical Home). Collaboration with the local Prepaid Health Plan network. Enter required data in Virtual Health. Provide care management services in accordance with the Care Management for High Risk Pregnancy Standardized Plan. Facilitate client/family in accessing appropriate services within the community. Assess psychosocial, nutritional (WIC referral), medical, educational and financial needs using Pregnancy Home Risk Screening forms and Comprehensive Needs Assessment. Counsel patients regarding the importance of early prenatal and continuous prenatal care and of keeping all appointments and following medical/nursing recommendations. Maintain good rapport with other agency staff as well as other service providers in the community. Serve as liaison with local physicians, Home Health, local hospital, Department of Social Services and Regional High Risk OB clinic. Additional Duties Continuously update knowledge and skills in Maternal, Child Health and Public Health. Serve on appropriate committees that focus on infant mortality and other issues which affect clients (subject to supervisor approval). Attend trainings, educational activities and monthly staff meetings. Act as an active member of the Care Management Team, providing input in ongoing caseload to ensure quality and continuity of care. Participate in disaster services as required and assist with department‑wide community activities (e.g., flu clinics, health fairs). Represent the Agency in court only when subpoenaed to testify. Complete any other duties assigned by the Social Work Supervisor and/or Health Director. Major Activities 90% Case Management (assessing the patient, family and environment; developing a care plan; counseling and education; referral and follow‑up; monitoring needs; serving as an advocate). 10% Resource Development / Community Liaison (serving as liaison with other service providers and attending job‑related workshops; promoting CMHRP by attending speaking engagements). Guides, Regulations, Policies and References Care Management for High Risk Pregnancy Standardized Plan. Local Health Department Policies, Procedures and Standing Orders. North Carolina Public Law – Confidential 130‑A143, Abuse or Neglect 7A‑543, Treatment of Minors 90‑21.5. Medicaid Guidelines. Other Work Characteristics This position may involve working in the patient’s home, exam room or agency office. In the patient’s home the care manager may be exposed to potentially hazardous conditions with patients who may be violent, mentally ill, or impaired with drugs or alcohol. Visits may be made in teams or with law enforcement assistance during extended hours. Adverse weather may necessitate rescheduling visits for safety. Minimum Training and Experience Requirements Bachelor of Social Work (BSW), BA in Social Work, or BS in Social Work from a CSWE‑accredited program; or Master of Social Work (MSW), MA in Social Work, or MS in Social Work. Registered nurses with appropriate credentials. Bachelor’s degree in a human service field with five or more years of care or case management experience with low‑income pregnant individuals and/or children ages 0 to 5 years. Bachelor’s degree in a human service field with three or more years of care or case management experience with the specified population and certification as a Case Manager (CCM preferred). License or Certification Required Valid North Carolina Driver’s License. #J-18808-Ljbffr Nash County, NC