Job Summary

This position will be responsible to manage the rising risk members in the population. The Health Partner will be the main point of contact for members and providers across care settings. The aim is to better manage members in ambulatory setting providing a variety of support functions which contribute to the overall improvement in members healthcare quality of life as well as efficient use of resources. Engages the appropriate resources within the multidisciplinary team to achieve optimal results for the patient, family, and care givers. This position provides comprehensive care coordination for patients as assigned. This position ensures adherence to the plan of care and develops, implements, monitors and documents the utilization of resources and progress of the member through their care, facilitating options and services to meet the members health care needs.

Essential Functions

• Manages individual patients across the health care continuum (longitudinal support) to achieve the optimal clinical, financial, operational, and satisfaction outcomes. Coachs members regularly regarding disease related symptom management. Advises members on lifestyle choices to improve prognosis and overall health. Provides patient monitoring, education, and supports patient care plan adherence.

• Provides self-management support. Including but not limited to: using checklists and escalating as prescribed by protocols, promoting healthy behaviors, imparting problem-solving skills, and assisting with the emotional impact of chronic illness, providing regular follow up and encouraging people to be active participants in their care.

• Applies the skills of motivational interviewing to promote the above lifestyle changes. Provides emotional support by showing interest, inquiring about emotional issues, showing compassion and teaching compassion.

• Establishes and promotes a collaborative relationship with physicians, payers, and other members of the health care team. Collects and communicates pertinent, timely information to payers and others to fulfill utilization and regulatory requirements. Bridges gaps between the member and the clinical team including but not limited to following up with members, asking about needs and obstacles, and addressing health literacy, cultural issues and social-class barriers.

• Meets and accompanies the patient and family to their initial appointments. Assists patients in navigating the health care system by connecting the client with resources, facilitating support and empowering the patient.

• Educates internal members of the health care team on care management and managed care concepts. Facilitates integration of concepts into daily practice.

Minimum Qualifications

Requires a Masters Degree in Social Work or related degree with three years of experience directly related to care management in health plan/mgmt./quality.

Requires a Licensed Master Social Worker (LMSW) (equivalent*) or Licensed Clinical Social Worker (LCSW). An equivalent license applies to states that do not recognize an LMSW; therefore, the employee must possess a Masters Degree and be a Licensed Social Worker.

Must have highly developed interpersonal and critical thinking skills with the ability to prioritize needs rapidly. This position requires the ability to convey messages and thoughts clearly to a diverse audience, using both verbal and written mediums. Requires the ability to promote change among patients. Responsible, caring and respect for older persons. Requires the ability to coordinate information and activities, work under stress of deadlines and frequent interruptions, and to possess analytical problem solving skills. Must possess excellent organizational skills, as well as effective human relations and communication skills. Computer literacy and keyboarding skills is required. Must be proficient in the use of system office applications. Must possess a basic understanding of integrated clinical systems. Provide own transportation, required to possess a valid drivers license and be eligible for coverage under the companys auto insurance policy.

Preferred Qualifications

Certification with nationally recognized healthcare organization, such as CCM, preferred.

Additional related education and/or experience preferred.