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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
