Social Work Manager jobs in Portland, OR

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JOB TITLE: Social Work Care Manager

SUPERVISOR: Director of Population Health

HOURS PER WEEK: 40hrs (Tuesday - Friday 7:00am - 5:30pm or 7:30am - 6:00pm)/Non-Exempt

DEPARTMENT: Population Health

HIRING BONUS: $1,000 after 90 days

*Partial remote position with 1-2 days in office per week and the rest work from home*

The following information is designed to outline the essential functions and position requirements of this job. It does not identify all tasks that may be expected, nor address the performance standards that must be maintained.

PRIMARY FUNCTION: To work collaboratively with physicians, staff and other health care professionals to provide a medical home and care coordination across the health care continuum for all patients enrolled in the Care Management Program. Act as an integral member of the health care team who works to ensure safety, best practice and high-quality standards of care are maintained across the continuum. Coordinate a wide range of self-management support for the Patient Centered Medical Home. Provide individuals, families and groups with the comprehensive psychosocial support and education needed to cope with chronic, acute, or terminal illnesses.

DUTIES AND RESPONSIBILITIES: (*ESSENTIAL FUNCTIONS)
1. Use a variety of patient identification sources to screen patients who may benefit from care management, according to high-risk criteria.*
2. Use appropriate assessment and intervention techniques, along with crisis and suicide management skills. Able to use range of interventions, depending upon the needs of the patient/family.*
3. Assess, develop, implement and monitor a comprehensive plan of care. Complete required documentation of services and care management per department policy.*
4. Promote multi-disciplinary care that is patient-centered and considers all aspects of patient’s personal, psychological, economic and cultural needs.*
5. Apply knowledge of resources and services available in the community, as well as knowledge of state and federal health regulations, in order to identify, plan, and arrange for appropriate services. Ensure effective planning and arranging for needed services upon discharge.*
6. Participate in program development, orientation, and educational activities which improve patient care and satisfaction*
7. Provide patient/family education and support, which furthers the patient’s capacity to better direct their own healthcare.*
8. Assess and evaluate each patient’s understanding of their disease process, treatment plan and/or lifestyle changes.*
9. Communicate care coordination, patient support, education, assessment, and appropriate interventions using telephone, email, and in person contact.*
10. Perform a variety of patient screenings by telephone and in person. Screenings may include but are not limited to, dementia, substance abuse, depression, anxiety, suicidality, and unmet social needs. Coordinate appropriate follow up after screenings.*
11. Work independently and collaboratively with interdisciplinary care team, in order to reach care plan goals. Facilitate communication among care team members.*
12. Make care/treatment recommendations to care team members based on assessment findings.*
13. Function as an active member of the Care Management team. Provide social work support/consultation to TPC RN Care Managers, physicians, and other clinical staff.*
14. Stay up to date on available community resources and provide information to TPC staff as needed.
15. Comply with HIPAA regulations at all times.*
16. Follow TPC guidelines for documentation, including completing forms and assessments and entering data into the computer and electronic health record (EHR).
17. Follow OSHA and TPC guidelines and policies for the prevention of the spread of bloodborne pathogens, including maintaining a clean work environment, use of safety and personal protective equipment and engineering controls.*
18. Maintain safety standards such as use of patient safety equipment, knowledge of emergency procedures, use of handrails on stairs, body mechanics and ergonomics.*
19. Collaborate with management to develop, implement and assess the Medical Home program objectives and processes. This includes education, recruitment and physician/clinic staff engagement and participation.*
20. Maintain regular work attendance and punctuality.*
21. Participate as an active team member in a patient-centered medical home.
22. Work respectfully and collaboratively in a team environment with a spirit of cooperation.*
23. Other tasks as assigned.

REQUIREMENTS:
Master of Social Work degree from an accredited school of Social Work
Two years relevant experience (either pre or post masters).
Current CPR Certification

PREFERENCES:
LCSW, LMSW or CSWA preferred.
Experience working in Mental Health/Crisis Intervention setting and/or experience working in substance abuse treatment setting.
Experience in Care/Case Management or Social Services
Knowledge of assessment, symptoms, and treatment of mental health diagnoses and chemical misuse/abuse/dependency.
Knowledge of evidence-based suicide prevention techniques and resources.
Ability to perform duties of the position telephonically and in person, including mental health evaluation and suicide/crisis intervention.
Demonstrate the ability to coordinate appropriate educational materials for patients and their support systems
Knowledge of and practical use of good business English, spelling, arithmetic, practices and the ability to communicate effectively using written and verbal skills
Demonstrate effective organizational skills
Demonstrate leadership as evidenced by previous work-related activities and performance
Demonstrate expert practice skills that include flexibility, priority setting, problem-solving, conflict resolution, negotiating and networking skills, decision-making, work delegation and organization, and verbal/written communication skills