Social Work Care Manager (3179, 3402)

PRIMARY DUTIES

• Coordinate and manage care for high-risk patients to improve outcomes and minimize unnecessary hospital utilization.

• Develop and maintain a tracking system for seamless care coordination across medical services, including transitions and referrals.

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

• Implement standing delegated orders and management protocols.

• Participate in or lead regular Care Team meetings.

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

• Offer coaching to patients on self-management for chronic conditions.

• Conduct comprehensive psychosocial needs assessments.

• Develop individualized care plans focusing on disease prevention and self-care improvement.

• Assist patients in navigating the healthcare system by coordinating with specialty care

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

OTHER DUTIES

• As assigned by supervisor.