Social Work (SW) Care Manager Plus - Palliative Care

Summary:

The Social Work (SW) Care Manager Plus, under the direction of a department Supervisor, applies graduate-level clinical social work skills to provide comprehensive, family-centered care management services to pediatric and young adult patients, included attributed managed care members, with complex medical, behavioral health, and psychosocial needs. This role applies the social work practice process (engagement, assessment, planning, intervention, monitoring, and evaluation) to ensure compliance with NCQA Complex Care Management (CCM) standards, promote interdisciplinary collaboration, improve population health outcomes, and reduce overall cost of care. The SW Care Manager Plus partners with children and young adults, and their caregivers to address social drivers of health, enhance access to services, and support optimal health and well-being.

Responsibilities:

1. Conduct outreach to pediatric patients and caregivers to support enrollment, engagement, and timely collection of health and psychosocial information.
2. Educate families on available support services and community resources.
3. Screen for social determinants of health and identify urgent health, safety, or welfare concerns using established protocols.
4. Escalate priority concerns to RN or Social Work Care Managers and route cases appropriately.
5. Maintain a caseload of low-risk patients and support continuity of services in alignment with productivity standards.
6. Assist families with accessing community resources, completing applications, and addressing barriers such as transportation and appointment adherence.
7. Track referrals, follow-up activities, and service connection status.
8. Share relevant patient information with RN and SW Care Managers in accordance with departmental workflows.
9. Support care managers with scheduling, task tracking, and case organization.
10. Assist with data collection, quality improvement initiatives, and program reporting.
11. Collaborate with interdisciplinary care team members, providers, and community agencies to coordinate family-centered care and transitions.
12. Document all patient interactions, needs, and outcomes accurately in compliance with organizational, regulatory, and confidentiality standards.
13. Other duties as required.

Other information:

Technical Expertise

1. Knowledge of pediatric health conditions, family dynamics, and child development principles applied through family-centered, trauma-informed, and culturally competent methodology.
2. Strong psychosocial assessment, crisis intervention, critical-thinking, and motivational interviewing skills with ability to manage and prioritize caseload effectively.
3. Excellent communication and collaboration skills with a commitment to quality improvement and cost-effective care delivery.
4. Familiarity with healthcare systems, insurance processes, and community resources.
5. Proficiency in MS Office [Outlook, Excel, Word] or similar software is required. Epic software or similar EMR software is preferred.

Education and Experience

1. Education: Master's degree in social work from an accredited Social Work academic program is required.
2. Licensure: Current, unrestricted licensure as a Licensed Social Worker (LSW) in Ohio is required.
3. Certification: Certification by a nationally recognized care management organization is preferred.
4. Years of relevant experience: Minimum 2 years of clinical experience in healthcare required. Experience in pediatric, ambulatory, care management and/or managed care is preferred.
5. Years of supervisory experience: none

Full Time

FTE: 1.000000

Status: Onsite