Purpose of Job: The LCSW Care Manager is responsible for all aspects of care for high risk members with chronic behavioral and/or health conditions, partnering with members and their caregivers, physicians and the health care team to provide timely access to ongoing and long term needed care, continuity of care across all settings, informed and shared decision making, and linkages to supportive services and community resources. This also includes palliative care.
Major Responsibilities:
Identify and document member’s goals.
Assessment of member’s medical and behavioral health, and social determinants of health.
Assess barriers to achieving goals including health status, functional abilities, behavioral health, social issues, environmental and safety concerns, caregiver stability, self-management skills, and life care planning.
Assess member’s strengths and confidence in achieving goals.
Monitor and evaluate plans including progress toward goals, health status, medication reconciliation and member experience.
Provide at least monthly contact with member:
home visits to evaluate home environments and family relationships, and to provide support and self-management coaching
medical and psycho-social appointments to facilitate collaboration
telephone calls
hospital visits
secure email
Perform psycho-social and psychiatric screening evaluations.
Review and interpret therapist reports and psychiatry reports.
Recognize and communicate with team any signs and symptoms of changing mental health needs.
Crisis management.
Link member and caregiver to supportive community services as needed and follow up to confirm contact.
Act as consultant to team members and fellow care managers regarding behavioral health conditions.
Facilitate access, communication and collaboration between member and all providers.
Provide and coordinate transition services across all settings of care:
Communicate care plan to all providers in all settings of care (Emergency Department, hospital, rehabilitation facility, home care, nursing home and specialists).
Ensure member, caregivers and providers receive timely information for treatment decisions across all settings.
Coordinate/verify services, equipment and supplies are in place.
Reconcile medications at every contact.
Regularly maintain records to document and monitor the care management activities in the management information system.
Participate in regular interdisciplinary case staffing meetings and reviews.
Communicate and collaborate with other providers (e.g., specialists, respiratory therapists, nutritionists, physical therapists, home health providers, care managers, social workers, etc.) by optimizing the office-based care team to send, receive, and triage information flows among the providers.
Communicate with, educate and advise members and family, helping them to understand conditions and treatments.
Participate in Quality Improvement activities.
Monitor identified performance measures and deliverables and provide regular progress reports - Report submission will be determined as performance measures and deliverables are identified.
Follow and practice defined evidence based protocols in all care management related activities and responsibilities.
Other duties as assigned.
Values:
Demonstrate and apply principles of person-centered, strength-based philosophy, motivational interviewing, shared decision making, coaching and adult learning
Demonstrate a sensitivity and responsiveness to a variety of cultural values and beliefs and social determinants of health
Practice trauma informed approach
Community Representative:
Serve as an OU representative on community boards and task forces
Qualifications:
Required Education: Master’s Degree in Social Work, AND:
24 months social work experience.
Working Conditions:
Environmental: Standard office environment.
Certifications or Licenses:
Licensed Master Social Worker (LMSW) from the Oklahoma State Board of Licensed Social Workers.
Basic Life Support Certification (BLS) to be obtained within 30 days of the hire date in this position.
Knowledge, Skills & Abilities:
Knowledge of the principles and practices of social and psychological casework.
Knowledge of social and welfare resources available in the community, hospitals, and clinics.
Knowledge of Medicare and Medicaid laws and guidelines, managed care contracts and other legal and regulatory requirements.
Ability to analyze and interpret a situation in order to determine a course of action to be taken.
Ability to explain technical data to patients, family members or caregivers.
Excellent communication skills
Must have interpersonal skills.
Ability to handle stressful situations.
Why You Belong at the University of Oklahoma: The University of Oklahoma fosters an inclusive culture of respect and civility, belonging, and access, which are essential to our collective pursuit of excellence and our determination to change lives. The unique talents, perspectives, and experiences of our community enrich the learning, and working environment at OU, inspiring us to harness our innovation, creativity, and collaboration for the advancement of people everywhere.
Equal Employment Opportunity Statement: The University of Oklahoma, in compliance with all applicable federal and state laws and regulations, does not discriminate based on race, color, national origin, sex, sexual orientation, genetic information, gender identity, gender expression, age, religion, disability, political beliefs, or status as a veteran in any of its policies, practices, or procedures. This includes, but is not limited to, admissions, employment, financial aid, housing, services in educational programs or activities, and health care services that the University operates or provides.
