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Summary:

The Community Based Health Manager is a member of the care team, along the patient’s medical provider and psychiatric consultant. Responsible for the clinical assessment, planning, implementation, monitoring and evaluation of case management services through the appropriate utilization of resources. Providing as needed short-term psychotherapy including motivational interviewing and behavioral activation Provides support to primary care clinician and behavioral health team including psychiatrist.

Application of appropriate medical necessity tools to maintain compliance, achieve cost effective care and positive patient outcomes. Utilizes clinical assessment, critical thinking and decision making to formulate coordination of care with a multi-disciplinary team, address patient plans of care and transition needs.

Facilitates ongoing patient communication and engagement, care planning, review patient goals, supports discharge needs including social resources, food insecurity, financial insecurity and transportation.  Networks with local/community services to identify appropriate resources for patient and family support. Facilitates patient handoff from post-acute service to the community for self-management.

Position Responsibilities:

Clinical Assessment – Conducts comprehensive assessments for chronic disease high risk patients and behavioral health using a standardized tool; will review GAD-7 and PHQ-9 with individuals, develops a patient centered individualized plan of care including patient goals and addresses patient’s psychosocial and educational needs. Identifies psychological, social, financial, spiritual and behavioral barriers that may interfere with the patient’s treatment plans and outcomes.

Care Coordination – Coordinates appropriate care through assessment and patient advocacy.  Communicates and educates patients, family and healthcare team on the plan of care and transition options ensuring patient freedom of choice. Provide brief behavioral interventions using evidence-based techniques such as behavioral activation, problem-solving treatment, motivational interviewing, or other treatments as appropriate. Makes appropriate referrals within the scope of available benefits to facilitate a patient-centered individualized plan of care.  Knowledgeable of community resources and facilitates appropriate services needed to meet needs of patient such as DME, HC, Meals on Wheels, transportation, medical insurance etc.

Quality – Understands quality, value-based metrics and preventative screening associated with chronic disease management. 

Communication – Communicates effectively with providers and care team the patient centered individual plan of care and assessment needs.  Coaches the patient/care giver to meet patient-centered individual plan of care goals.

Documentation – Appropriate and complete documentation of assessments, patient centered individualized plan of care including treatment goals and patient/care giver education in patient record.  Documents update in treatment goals and preventative interventions in patient record. Follows Virtua Health and National Association of Social Workers (NASW) guidelines for documentation, while upholding patient confidentiality.

Compliance – Understands and applies applicable federal and state regulatory requirements.

Participates in organizational improvement activities, including patient satisfaction teams, reduction in patient hospital utilization, departmental/divisional teams, and community events.

Position Qualifications Required / Experience Required:

Required Experience:

Required:  Must be a Licensed Social Worker

Excellent verbal and written communication skills, problem solving, critical thinking organizational skills and conflict resolution.

Preferred:  UR/CM/QM experience or 3 years' experience as Clinical Social Worker in acute care. Knowledge of quality metrics.

Competent computer and technology experience

Basic understanding of Medicare, Medicaid and managed care. 

Required Education:

Graduate of an approved School of Social Work with a master’s degree.  

Training / Certification / Licensure:

Licensure from the State of New Jersey as a Social Worker.