Social Worker (LCSW) MD Medicare (In Office)

PURPOSE :

The Social Worker (SW) role would be assisting the needs of members in the field on a daily basis.

The Social Worker (SW) may support the Care Managers and Director of Care Management for the Commercial Population or the Temporary Assistance for Needy Families (TANF) and Heathy Families populations.

They are to ensure available resources are being used in a timely and cost-effective manner to obtain optimum value for both the member / enrollee and the reimbursement source.

The SW will adhere to the principle of the Quadruple Aim improving member / enrollee experience, improved clinical outcomes, lower costs while pursuing health equities for our members / enrollees and retaining staff.

The SW will be fully engaged in the team direction, address problems and provide guidance to members of the team to meet established performance metrics and performance guarantees.

The SW is part of an effective, efficient workforce to support all aspects of the Care Management department across the continuum of care settings, clinical programs and services for members / enrollees.

This includes the planning, implementation, and refinement of Care Management services, interventions and initiatives that support departmental and divisional goals.

Depending on the specific business area, the SW will support the role of the Care Coordinators and Community Health Worker.

The role works closely with the Care Manager, Supervisor or Manager to develop and operationalize sustainable processes to support functional improvements for the organization.

ESSENTIAL FUNCTIONS :

CARE MANAGMENT PROCESS

• I dentification / Risk Stratification : Engages members / enrollees into Care Management (outreach and successful enrollment) using diagnostic cost grouper classification reports which identify the relative risk score, illness burden, catastrophic health care users with significant health care costs and the High Intensity care needs.
• Assessment : May gather clinical information including past medical history, medications, physical / psychosocial factors, cultural influences, evaluation of health care barriers to include available support systems, available benefits and community resources for the comprehensive assessment of the member / enrollee’s medical, behavioral health needs and Social Determinants of Health.

Obtains verbal consent to initiate case Care Management services and interventions.

Planning : Utilizes proficient Care Management clinical knowledge and experience to assist in coordination of integrated care- plan development involving the member / enrollee, family, Hospital Transition of Care (TOC) nurse, Care Coordination (CC), Care Manager (CM), Primary Care Physician (PCP), specialists and other healthcare providers / vendors as appropriate.

Goals developed will be member centric, prioritized, action-oriented and time-specific to stabilize the health care condition and meet NCQA standards of documentation for Care Management Accreditation.

Facilitation of communication and Care Coordination : Executing the transition of care includes moving the member / enrollee from one healthcare practitioner and setting as appropriate to another as their healthcare needs change.

Key responsibilities of the SW is to minimize the fragmentation of care services and adverse outcomes. Complete a review of service request when appropriate containing all appropriate information (clinical, medical policy, contact / complex benefit structure, FDA treatment, clinical trials and drugs) to allow the medical director to make a medical necessity determination.

Identifies and provide educational and community resources, support groups, pharmacy program and financial assistance.

• Monitoring : Documentation will reflect the communication with the member / enrollee, family, physicians, and other health care providers to ensure the member / enrollee’s progression in meeting the established care plan goals.
• Outcomes Management : Evaluate the extent to which the established goals in the plan of care have been achieved.
• Care Management documentation is completed on the specific departmental platform / system. Confirm member / enrollee eligibility and available benefits.
• Participates in the preparation and on-site reviews (NCQA, OSR and DHCF as appropriate).
• Responsible for completion of documentation review and peer to peer audit as assigned by management Responsible for adherence to the departmental SOPs, NCQA Complex Care Management Standards and Health Plan Standards.
• Adheres to the CMSA Standards of Practice for Case Management.
• Maintains confidentiality of patient information according to HIPAA and departmental policies.
• Other duties as assigned by management.
• Other duties as assigned per divisional requirements and needs of the members / enrollees. The SW may be tasked with episodic interventions involving the domains of social determinants of health such as housing, food insecurities, economic stability, education quality and access, neighborhood and environmental.

The SW will be available to assist and lead interventions in crisis situations suicide attempts, acute domestic violence events such as assisting with safe passage to shelters / ER as needed.

The SW may assist with transportation benefits as needed. The SW will also assist in referring to mental health providers and / or facilities as needed.

QUALIFICATIONS :

Education Level : Master's Degree in LICSW - Licensed Independent Clinical Social Worker or LCSW- Licensed Clinical Social Worker.

Licenses / Certifications :

LCSW- License Clinical Social Worker LICSW - Licensed Independent Clinical Social Worker or LCSW- Licensed Clinical Social Worker Upon Hire.

Experience : 5 years Proven experience in a clinical social work role.

Knowledge, Skills and Abilities (KSAs)

• Knowledge of patient rights and laws relative to those rights, such as HIPAA.
• Ability to remain patient and calm in stressful situations.
• Excellent communication skills both written and verbal.
• Ability to build comprehensive reports and effectively convey information to others.
• Knowledgeable of federal / state mandates as they apply to various plan contracts.
• MCG Chronic Care Guidelines : Familiarity with and usage of for the purpose of discharge planning.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence.

Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Department

Department :

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.