Resp & Qualifications
The Social Worker supports the CM Care Manager and Director of Case Management for Medicare Advantage members, while ensuring that available resources are being used in a timely and cost-effective manner in order to obtain optimum value for both the enrolleee. The Social Worker will adhere to the principle of the Quadruple Aim – improving enrollee experience, better outcomes, improved clinical experience, lower costs while pursuing health equities for our enrollees.The Social Worker will take part and be fully engaged in the team direction, address problems and provide guidance to members of the team to ensure the team meets established performance metrics and performance guarantees. The Social Worker is part of an effective, efficient workforce to support all aspects of the Case Management department across the continuum of care settings and clinical programs and services for enrollees. This includes the planning, implementation, and refinement of case management programs and initiatives for medical management that support departmental and divisional goals. Depending on the specific business area, the Social Worker can support the role of Care Coordinators and Community Health Worker. The role works closely with the CM Care Manager and Supervisors to develop and operationalize sustainable processes to support functional improvements for the organization.
Identification/Risk Stratification: Engages enrollees into the case management program (outreach and successful enrollment) who are identified. Identifying catastrophic health care users with significant health care costs related to frequent Emergency Room utilzation in lieu of primary care provider. Conducts and documents a comprehensive assessment of the enrollee’s health psych/social needs, including health literacy and deficits. Obtains verbal consent to initiate case management services. Gathers clinical, which includes past medical history, medications, physical/psychosocial factors, cultural influences, evaluation of health care barriers to include available support systems, available benefits, community resources, and treatment and medication compliance according to NCQA Case Management Accreditation.Planning: Proficient case management clinical knowledge and experience to coordinate integrated care-plan development involving the enrollee, caregivers, and other individuals of the interdisciplinary care team. Goals developed will be prioritized, action-oriented and time-specific to stabilize the complicated health care condition and meet NCQA standards of documentation for Case Management . Facilitation of Communication and Care Coordination: Executing the transition of care includes moving the enrollee from one healthcare practitioner and setting to another as their healthcare needs change. . Identifies and provide educational and community resources, support groups, pharmacy program and financial assistance. Monitoring: Documentation will reflect the necessary communication with the enrollee, family, physicians, and other health care providers to ensure the enrollee’s progression in meeting the established care plan goals. Evaluate the extent to which the established goals in the plan of care have been achieved.
Case management documentation is completed in the Guiding Care system. Confirms enrollee eligibility and available benefits. Participates in the preparation and on-site reviews. Responsible for completion of documentation review and peer to peer audit as assigned by management. Responsible for adherence to the NCQA Complex Case 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
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education Level: Master's Degree
Education Details: LCSW- Licensed Clinical Social Worker
Experience:5 years Proven experience in a clinical social work role
Department: MD Medicare Advantage
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.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 10/13/21
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship
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