Social Worker Case Manager, Integrated Health

A Brief Overview

Integrated Health Case Manager (COMMUNITY BASED) works directly with patients who have chronic andcomplex medical conditions, potentially with additional behavioral health concerns and socio-economic barriers.This role engages in intensive community-based case management and care coordination to help improvepatient quality of life, health outcomes and efficient utilization of health system services. This role uses behavioral health techniques and interventions to help patients remove barriers to care and promotes meaningful behavior change to support improved health. This position embraces a program culture of intensive outreach efforts and relationship building, is part of a multidisciplinary team and actively utilizes data to help guide care.

What You Will Do

• Support the behavioral and physical health care of patients with chronic conditions to help improve quality of life and health outcomes while promoting effective utilization of health system services.
• Participate in completion of a biopsychosocial assessments. Develop comprehensive treatment plans to help remove barriers to care so that patients can achieve personal health goals. Provide referrals and recommendations for indicated services and/or treatments and assist patients in obtaining those services.
• Establish trusting and supportive therapeutic relationships with patients; utilize behavioral health techniques and interventions to help foster positive behavior change for all aspect of health. Maintain frequent in-person and community-based contact with patients. Participate in a shared case-load, team approach to care.
• Provide patients with educational materials for behavioral and physical health conditions
• Provide comprehensive care coordination with internal and external providers and assist patients with all aspect of their care including scheduling and attending appointments, joining appointments when appropriate, initiating case consultations as needed, and assisting with follow-up recommendations.
• Incorporate the use of real-time data to ensure timely response to urgent situations.
• Complete timely and accurate documentation while following program policies and procedures to ensure overall compliance.
• Actively engage in regular team consultations and clinical supervision.

Additional Responsibilities

• Performs other duties as assigned.
• Complies with all policies and standards.
• For specific duties and responsibilities, refer to documentation provided by the department during orientation.
• Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.