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Job Description: OVERVIEW OF POSITION: The Care Manager (Social Worker) is responsible for delivering clinically and psychosocially informed, person-centered care management services to Medicaid members with complex physical, behavioral health, and social determinants of health. This role conducts comprehensive clinical and/or biopsychosocial assessments, manages Transitions of Care (TOC) and other high-risk outreach, develops individualized care plans, and supports members through care coordination, system navigation, and condition management. The Care Manager is a licensed professional who collaborates with interdisciplinary and multi-agency teams to ensure coordinated, high-quality care that improves member engagement, stability, health outcomes, and reduces avoidable utilization. This role requires comfort with outbound outreach, including cold-call engagement of hard-to-reach members, to meet program productivity standards and contractual performance requirements. ESSENTIAL DUTIES:
• Perform comprehensive clinical and/or psychosocial assessments for assigned high-risk, medically complex, and high-barrier members . • Develop, implement, and update individualized care plans addressing medical, behavioral health, psychosocial, and environmental needs. • Manage transitions of care following hospitalization, emergency department utilization, facility stays, behavioral health transitions, or other acute episodes. • Complete all required follow-up for transition-of-care and assigned populations within established timelines. • Conduct ongoing care management, monitoring, and coordination for designated members . • Identify and address barriers affecting adherence, recovery, stabilization, and follow-up, including housing, transportation, food insecurity, caregiver support, financial strain, behavioral health, and substance use concerns. • Coordinate care with PCPs, specialists, behavioral health providers, facilities, caregivers, interdisciplinary teams, and community agencies. • Connect patients to community resources, social services, behavioral health resources, and support programs. • Provide patient and caregiver education related to disease management, self-management, care navigation, resource access, and next steps in care. • Utilize motivational interviewing, engagement strategies, and de-escalation techniques to support member participation and goal attainment. • Escalate urgent clinical, psychosocial, crisis, safety, or member-protection concerns appropriately. • Collaborate with interdisciplinary teams to support integrated, person-centered care delivery. • Maintain timely, accurate, and compliant documentation across assessments, care plans, outreach, follow-up, and coordination activities. • Maintains a high level of confidentiality and ensures compliance with HIPAA regulations • Assist with planning, coordinating, and representing the organization at community events designed to retain existing members and generate awareness among prospective members. • Deliver educational presentations to existing and prospective members at community events, clinics, and partner sites: evening and weekend availability is required to support scheduled events and community programming. • Other duties as assigned
POPULATION SERVED:
• Medicaid and designated high-risk, complex member populations • Member requiring transition-of-care support • Member with repeated utilization, worsening acuity, or chronic-condition instability • Member with psychosocial, behavioral health, environmental, or social determinants of health barriers • Member requiring community-resource linkage and psychosocial intervention • Other assigned populations as applicable
EDUCATION: Active Master of Social Work (MSW) with active applicable licensure in good standing. Must be licensed in the state where the assigned population is served.
EXPERIENCE: 1+ years of experience in care management, care coordination, case management, behavioral health, social work, utilization management, transitional care, or related experience. Experience working with high-risk, medically complex, behavioral health, or psychosocially complex populations. Experience supporting transitions of care. Preferred experience:
• Experience with Medicare Advantage, Medicaid, DSNP, and/or CSNP populations. • Experience in value-based care, managed care, or population health. • Case management certification or related credential. • Bilingual capability, where relevant to market needs
KNOWLEDGE, SKILLS, ABILITIES:
• Knowledge of community resources and behavioral health supports. • Proficiency with EMR and care-management documentation systems. • Complete assessments, care plans, outreach, and follow-up activities within required timelines. • Complete transition-of-care follow-up within organizationally defined timeframes. • Maintain timely and compliant documentation across all care management activities. • Meet expectations related to care-plan completion, case progression, barrier resolution, and member engagement. • Escalate urgent or deteriorating clinical, psychosocial, or safety concerns promptly. • Meet role-specific LPIs/productivity expectations and delegated responsibilities. • Strong clinical and/or psychosocial assessment and intervention skills • Strong care planning and coordination capability • Knowledge of behavioral health, community-resource systems, and social determinants of health • Strong crisis support and de-escalation ability • Ability to manage medically complex and high-barrier patients across settings • Strong communication and collaboration with providers, caregivers, and interdisciplinary teams • Motivational interviewing and patient engagement skills • Strong documentation, follow-through, and compliance discipline • Ability to prioritize risk and intervene appropriately • Ability to manage sensitive and complex cases professionally • Home office, that is HIPAA compliant for all remote or telecommuting positions as outlined by the company policies and procedures
Salary Range: Salary Range: $63,502.40- $81,000 Additional Compensation: Eligible for annual bonus based on individual and/or company performance. Benefits: Includes medical, dental, and vision insurance; 401(k); paid time off (PTO); and Employee Assistance Program (EAP) Application Deadline: Open until filled. Applications will be reviewed on a rolling basis. How to Apply: Apply via careers page at https://alpinephysicians.wd1.myworkdayjobs.com/external