Description

SKILLS

• Knowledge of health care conditions and needs of children and pregnant women.


• Ability to learn and apply case management and patient education skills.


• Strong interpersonal skills with the ability to build effective relationships across medical teams and with patients.


• Proficiency in problem identification and care plan development.


• Professional interaction skills with medical providers and other healthcare professionals.


• Skillfully conduct health assessments and screenings.


• Ability to learn and apply evidence-based behavioral strategies.


• Strong written and oral communication skills.

PRIMARY DUTIES

• Coordinate and manage care for high-risk children and/or pregnant women to improve outcomes.


• Assess and respond to psychosocial, financial, functional, cognitive and medical needs.


• Identify and address gaps in patient care through proactive outreach and follow-up services.


• Identify and utilize patient’s systems of support and facilitators for reaching health goals.


• Monitor and respond appropriately to changes in patients’ condition, resources, or services.


• Serve as a liaison between primary care, specialty, and behavioral health services for coordinated patient treatment plans.


• Conduct comprehensive psychosocial needs assessments.


• Develop individualized care plans focusing on short and long-term medical and behavioral health treatment goals.


• Assist patients in navigating the healthcare system.


• Apply knowledge of community resources to address care gaps or improve quality of life conditions.

OTHER DUTIES

• As assigned by supervisor.

Qualifications

 Social Work Care Manager

Children & Pregnant Women

REPORTS TO: Director of Care Management and Social Work Care Management Team Lead

EDUCATION & EXPERIENCE

• LMSW


• Preferred:
  
  
  
  • Experience in social services, counseling, or case management
  
  
  • Experience providing social services in healthcare settings
  
  
  
  

TERM: Funding is secured through October 31, 2027. This revenue-generating role is expected to evolve into a self-sustaining, ongoing position, and every effort will be made to continue the role beyond the initial term.

PHYSICAL AND MENTAL REQUIREMENTS

• Possess a valid Texas driver’s license and appropriate liability insurance


• Access to personal transportation


• Visual and auditory accuracy


• Shift length varies


• Indoor setting


• Continuous use of computer


• Long periods of sitting


• Frequent use of telephone and/or smart devices


• Continuous repetitive grasping and manipulation of both hands


• Continuous conversational communication


• Occasional reaching, walking, squatting, bending, kneeling, twisting and climbing


• Occasionally carrying, lifting, pushing and pulling of up to 25 lbs.


• Occasionally working in confined, noisy, dusty areas


• Understand/carry out simple/detailed, oral/written instructions


• Memorize and retain instructions


• Read and interpret detailed specifications


• Mental competency


• Tobacco non-user


• Physical accommodations will be implemented where necessary and feasible