Per Diem Clinical Care Manager, Social Worker, Advanced Illness Management Progr

• Personal and financial wellness programs
• Opportunities for professional growth and career advancement
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities
• Referral bonus opportunities

What You Will Do

• Educate and guide members and families on advance directives, living wills, and healthcare proxies.

• Facilitate discussions around goals of care, treatment preferences, and end-of-life wishes.

• Conduct thorough assessments of the member’s emotional, social, cultural, and spiritual needs.

• Respond to urgent psychosocial needs, including caregiver burnout, family conflict, or emotional distress.

• Identify support systems, caregiver dynamics, and potential barriers to care.

• Coordinates and/or oversees the coordination of benefits and services for all members on his/her caseload.
• Completes care management and disease specific assessments.
• Makes timely telephonic care management calls based on risk level.
• Resolves and coordinates complex issues and member complaints impacting the delivery of services.
• Provides health education to member/caregiver.
• Assess SDoH and provide care coordination to reduce/remove barriers of care to include ability to allow for changing levels of care based on assessments, trigger events and program data/reports.
• Coordinates the delivery of high quality, cost-effective care based on a customized population model of care supported by evidence based clinical practice guidelines.
• Advocates for the member/caregiver to obtain the health care and other services needed to optimize their quality of life.
• Utilizes the Care Management process to set priorities, plan, organize and implement interventions that are goal directed towards self-care outcomes and the transition to independent status.
• Promotes adherence to the physician treatment plan by providing education, coaching and support.
• Educates, coordinates, and provides resources to reduce inappropriate utilization of emergency room (ER) and hospital service.
• Increases utilization of primary care, specialty care, preventive health and guideline-based treatments including proper pharmacotherapy within network, as appropriate.
• Participates in interdisciplinary team (IDT) meetings and provide input on customer service-related activities.
• Protects the confidentiality of member information and adheres to company policies regarding confidentiality.
• Ensures compliance with payors’ policies and procedures as well as all Federal and State regulations.
• Interprets and implements VNS Health policies, state and federal regulations.
• Participates in special projects and performs other duties as assigned.