Social Work Case Manager II

Job Summary Responsible for providing a wide range of social work and medical case management services to CBHS patients and families, with the goal of addressing social determinants of health that directly impact access to and engagement in medical care and treatment. Service delivery shall include patient screening, comprehensive psychosocial assessment, service or care planning, referral and linkage to resources, progress monitoring and reassessment, crisis intervention, and supportive counseling. As a member of the medical care team, Social Workers provide consultation and support regarding concrete needs and financial services to CBHS providers and patients. Additionally, Social Workers facilitate applications for Social Security, Medicaid and Medicare programs, and Affordable Care Act enrollment. Social Work services are made available to primary care, obstetrics/gynecological, pediatric, dental, behavioral health, LHRC, and infectious disease patients with general, specialized, or complex needs. Key Responsibilities Provides supportive counseling for patients and families as per CBHC policy. Performs comprehensive intake assessments and completes all necessary documentation duties. Completes assigned triage and clinic duties in a thorough, timely, and accurate manner. Provides a wide range of social work case management and outreach services to patients and families, including assessment, linkage to resources, planning, monitoring, crisis intervention, and coordination with other team members. Executes aspects of assigned departmental or organizational plans for care and services to diverse patient populations and facilitates awareness of such populations. Facilitates psycho‑educational and social/clinical support groups as necessary for targeted CBHC patients. Demonstrates advanced knowledge of existing community resources and how to access them to improve social determinants of health. Coordinates information, caseload priorities, and referrals and follows up on them in a timely, accurate manner. Reviews patient needs, acuities, care plan, and engagement through periodic case consultation with supervisor. Works with providers, the health care team, and the community and educates them about medical case management services through in‑services and communication. Participates in interdisciplinary team meetings and staff meetings as appropriate, providing consultation to medical providers and other CBHC staff to facilitate coordinated continuum of care. Ensures documentation is accessible to the patient’s care team and keeps care plans updated to address medical case management needs. Maintains accurate data for reporting to funders and partners and develops relationships with appropriate community resources. Documents all services as directed by CBHC policy, State requirements, and professional standards and adheres to departmental and policy procedures. Demonstrates appropriate use of billing, grant, or order coding for all EHR documentation. Utilizes the Electronic Health Record to support and improve integrated healthcare. Demonstrates ability to engage patients and/or families who are not engaged in services through outreach and follow‑up and refers them to CBHC and community resources. Participates in outreach activities, events, trainings, and networking and educational opportunities as appropriate. Skills and Abilities Ability to work effectively with patients and families who have social, economic, emotional, behavioral or health problems. Ability to develop, initiate and follow through with an appropriate plan of service. Ability to provide services to patients and families and treat personal information discreetly and confidentially. Ability to establish and maintain effective working relationships with staff members, other agencies and the general public. Education and Experience Required: Master’s Degree in Social Work. Active Maryland State Social Work License (LGSW, LCSW, LCSW-C) as specified and required for the Ryan White grant. MHBE Insurance Assister/Counselor Certification within one year of hire. Three years of related experience in a health care setting and community, case management, and/or outreach experience. Working Conditions/Physical Demands Work is typically performed in an office environment. #J-18808-Ljbffr