Duties and Responsibilities (including but not limited to)
- Assess identified members to determine members appropriate for management early in their disease process and at any time during the continuum of care.
- Complete a comprehensive assessment to identify patient risk and develop a care plan utilizing expertise and judgement to evaluate needs for alternative services as needed.
- Assess members’ Social Determinants of Health, such as housing, food, transportation, and safety in the home.
- Work collaboratively with physicians and community resources including pharmacists, nurses, registered dieticians and other disciplines to address patient needs as identified in assessments.
- Assess and screen members for behavioral health concerns (depression / substance abuse) utilizing screening tools, including the PHQ2 and 9 Depression screenings, and insure they are receiving appropriate behavioral health interventions.
- Develop, facilitate, and communicate a plan of care in partnership with the member, family (or designated representatives), providers, and multidisciplinary care team to assess the options of care including use of benefits and community resources.
- Coordinate necessary referrals and authorizations pertinent to patient care and well-being.
- Utilize developed systems, processes, and initiatives to engage patients in relevant social activities necessary to promote wellness and care at the right place and time.
- Facilitate member adoption of strategies to promote physician recommended behavior changes.
- Identify and utilize cultural and community resources and align with the patient’s cultural preferences as much as possible.
- Coordinate care and communicate with multiple providers, internal and external to the practice.
- Act as a resource for both clinical and non-clinical staff [i.e. care coordinators, dieticians, RN Case Managers].
- Attend required training and collaboration sessions [i.e., learning sessions/ practice team meetings] as scheduled.
- Provide and facilitate open communication, regarding patient status, with physicians and patient care team.
- Develop constructive relationships with internal GLIN population health team members, participating providers, and community resources.
Qualifications or Education, Training and Experience
- Valid and current LCSW or LMSW licensure
- 3-5 years’ care management and/or managed care experience in one of the following settings: acute inpatient, rehabilitation, sub-acute, skilled facility, homecare, ambulatory care management, or managed health plan.
Working knowledge of the following required:
- Timely and accurate documentation of day-to-day activities in designated technology platform.
- Adaptable to new technologies and software.
- Proficiency in EMR system(s), Outlook and data entry experience preferred.
- Basic PC skills (MS Word/Outlook/PPT/Excel).
- Knowledge of Federal and State regulations for Medicare and Medicaid and other national and state funded programs.
- Knowledge of community resources access.
Examples of Competencies:
- Ability to use independent judgment and to manage and impart confidential information.
- Ability to analyze and solve problems; requires details, data and facts that must be analyzed and challenged prior to making decisions.
- Strong communication, listening interpersonal skills.
- Ability to clearly communicate medical information to professional practitioners and/or the public.
- Excellent organization, prioritization, follow up, analytical and time management skills with ability to handle multiple priorities and deadlines
- Good interpersonal skills, sense of urgency, being proactive and ownership for one’s work.
- Dependable, with strong work ethic and extremely high degree personal integrity.
- Ability to deal with multiple interruptions on a continual basis that must be met with a friendly exchange with others.
- Ability to develop and implement new approaches to improve processes, procedures, or the general work environment.
- Ability to review critical issues, effectively solve problems and create action plans.
Our culture encourages individual development, embraces an inclusive environment, rewards innovative excellence, and to lead New York in provider and patient satisfaction. Great Lakes Integrated Network (GLIN) values diversity, inclusion, and equity as matters of fairness and effectiveness. We are committed to hiring and retaining a staff that reflects the diversity of the communities we serve, fostering an inclusive working environment where staff of all backgrounds feel welcomed and engaged.
Great Lakes Integrated Network is an Equal Opportunity Employer
Please send cover letter and resume via email to firstname.lastname@example.org and in the subject line please indicate the position you are applying for.
Great Lakes Integrated Network
726 Exchange Street
Buffalo, NY 14210