Social Worker III- TULSA

OU Sooner Health Access Network   

LCSW Care Manager Job Description 

Purpose of Job: The LCSW Care Manager is responsible for all aspects of care for complex high risk members with chronic behavioral and/or health conditions, partnering with members and their caregivers, physicians and the health care team to provide timely access to ongoing and long term needed care, continuity of care across all settings, informed and shared decision making, and linkages to supportive services and community resources.  This also includes palliative care.

Major Responsibilities:

• Collaborate with members to create a member’s plan of care, including identifying goals, barriers and strengths.
• Clinical assessment of member’s medical and behavioral health, and social determinants of health.
• Assess barriers to achieving goals including health status, functional abilities, behavioral health, social issues, environmental and safety concerns, caregiver stability, self-management skills, and life care planning.
• Assess member’s strengths and confidence in achieving goals.
• Conduct ongoing medication reconciliations including assessing for barriers.
• Monitor and evaluate plans including progress toward goals, health status, medication reconciliation and member experience.
• Review and interpret medical test results.
• Evaluate effectiveness of medical treatments.
• Depending on the care management pathway followed, contact is provided daily to at least monthly to members: 

o   home visits to evaluate home environments and family relationships, and to provide support and self-management coaching.

o   medical and psycho-social appointments to facilitate collaboration

o   telephone calls.

o   hospital visits.

o   secure email.

• Understands and is able to apply the concepts of disease management and risk management in service planning.
• Utilize critical thinking to assess alternative approaches to problems and/or decisions.
• Perform psycho-social and psychiatric screening evaluations.
• Review and interpret therapist reports and psychiatry reports.
• Recognize and communicate with team any signs and symptoms of changing mental health needs.
• Crisis management.
• Link member and caregiver to supportive community services as needed and follow up to confirm contact.
• Act as consultant to team members and fellow care managers regarding behavioral health conditions.
• Facilitate access, communication and collaboration between member and all providers.
• Provide and coordinate transition services across all settings of care.

• Communicate care plan to all providers in all settings of care (Emergency Department, hospital, rehabilitation facility, home care, nursing home and specialists).
• Ensure member, caregivers and providers receive timely information for treatment decisions across all settings.
• Coordinate/verify services, equipment and supplies are in place.
• Reconcile medications at every contact.
• Regularly maintain records to document and monitor the care management activities in the management information system.
• Participate in regular interdisciplinary case staffing meetings and reviews.
• Communicate and collaborate with other providers (e.g., specialists, respiratory therapists, nutritionists, physical therapists, home health providers, care managers, social workers, etc.) by optimizing the office-based care team to send, receive, and triage information flows among the providers.
• Communicate with, educate and advise members and family, helping them to understand conditions and treatments.
• Participate in Quality Improvement activities.
• Monitor identified performance measures and deliverables and provide regular progress reports - Report submission will be determined as performance measures and deliverables are identified.
• Follow and practice defined evidence-based protocols in all care management related activities and responsibilities.
• Conduct assessments and monitoring within prescribed timelines.
• Other duties as assigned.

Values:

• Demonstrate and apply principles of person-centered, strength-based philosophy, motivational interviewing, shared decision making, coaching and adult learning
• Demonstrate a sensitivity and responsiveness to a variety of cultural values and beliefs and social determinants of health
• Practice trauma informed approach

Community Representative:

• Serve as an OU representative on community boards and task forces

Job Qualifications:

• Licensed Clinical Social Worker (LCSW), or Licensed Social Worker (LSW) with at least three years’ experience in social work/health services care management
• License in good standing in the state of Oklahoma
• Completion of the OSDMHSAS Behavioral Health Care Management Certification required
• Excellent oral and written communication skills

Equal Employment Opportunity Statement:  The University of Oklahoma, in compliance with all applicable federal and state laws and regulations, does not discriminate on the basis of race, color, national origin, sex, sexual orientation, genetic information, gender identity, gender expression, age, religion, disability, political beliefs, or status as a veteran in any of its policies, practices, or procedures. This includes, but is not limited to, admissions, employment, financial aid, housing, services in educational programs or activities, and health care services that the University operates or provides.
Diversity Statement:  The University of Oklahoma is committed to achieving a diverse, equitable, and inclusive university community by recognizing each person's unique contributions, background, and perspectives. The University of Oklahoma strives to cultivate a sense of belonging and emotional support for all, recognizing that fostering an inclusive environment for all is vital in the pursuit of academic and inclusive excellence in all aspects of our institutional mission.