Care Manager - LCSW

At Playground Pediatrics, we believe every child deserves the highest quality care. We are building a multi-state, value-based pediatrics practice enhancing the patient and provider experience while delivering improved outcomes. Together, our goal is to create a more supportive, seamless, and comprehensive approach to meet the unique needs of every child entrusted to our care.

Position Description:

The primary role of the care manager is to provide proactive whole person care management services that address the needs of individual patients. The care manager works closely with families, providers, clinical teams, and community resources to support care coordination and improved access to enhance the health outcomes of our patients. The care manager is responsible for the assessment, care planning, and coordination of care and services, including ongoing monitoring of an appropriate and effective person-centered care plan, patient education and care management.

Key Responsibilities:

• Perform comprehensive assessment and reassessment of patients clinical and psychosocial needs, alongside strengths and barriers to care.
• Collaboratively develop, monitor and update an individualized family-centered care plan based on practice-based risk stratification, comprehensive assessment and collaboratively defined goals.
• Assess patients via face-to-face encounter or by telephone to determine care management or care coordination needs. Care management goes beyond office based clinical diagnosis and treatment.
• Coordinate care and services across healthcare providers, outpatient therapies, community-based organizations, schools, and state- and local-services to meet patient’s needs and goals.
• Educate families on conditions, care plans, medications, and available resources including health plan benefits.
• Identify barriers for care coordination and appropriate care management interventions.
• Provide coaching and motivational interviewing to engage families, support behavior change, and empower participation in achieving health goals.

Transitional care management

• Provide transitional care management to identified patients using ADT alerts for those patients who have an ED visit or hospital admission/discharge/transfer and who are at risk of readmissions and other poor outcomes.
• Facilitate clinical handoffs – including obtaining discharge plan, conducting medication reconciliation, following up with the patient after discharge, and coordinating outpatient follow-up, home visit, or face-to-face encounter.

Documentation

• Maintain accurate, timely, and thorough documentation in care management platform and electronic health record.
• Complete and submit required documentation, reporting and logs as assigned by supervisor.

Communication & Collaboration

• Demonstrate cultural competence and sensitivity in working with culturally diverse patient populations.
• Frequently update and work closely with other care team members including providers, clinical teams, care managers, care navigators, referral coordinators, community resources, patients and families, and other care team members.
• Participate in care team huddles, case conferences, quality improvement and program meetings.

Leadership

• Direct care coordinator, community health navigator or care-extender activities to support the health of the patient.
• Support a culture of quality improvement across practices.
• Listen and incorporates feedback.

Other

• Flexibility of work schedule is required, with some weekend and evening hours as needed to support the patient.
• Ability to travel to local practices and community agencies as needed.
• Participation as necessary in the practices on call coverage system to ensure patients are appropriately supported.
• Perform other duties as assigned by their supervisor within this scope.

Requirements:

• A current LCSW license in North Carolina (NC) is required
• At least three (3) years of experience working as a Licensed Clinical Social Worker (LCSW) is required

Preferred Qualifications:

• 3-5 years of care management experience
• Bilingual Spanish
• Pediatrics experience in the outpatient, inpatient, or emergency department setting
• Value-based care experience
• Passionate and committed to improving the health and well-being of children and their families
• Solution-oriented and able to navigate challenging people situations
• High emotional intelligence with excellent communication and interpersonal skills, and the ability to build trust with patients and families
• Ability to thrive in a fast-paced, dynamic environment and adapt to changing priorities
• High level of integrity, humility, and professionalism
• Ability to apply and utilize evidence-based clinical guidelines
• Ability to lead an interdisciplinary care team
• Strong organizational skills
• Comfort conducting home visits or providing services in the community
• Strong computer skills and has a willingness to learn additional skills