Care Manager JOB SUMMARY The Care Manager provides social services within the scope of MSW/ BSW practice standards in collaboration with primary care physicians and other members of the health care team and teaches and educates patients and their families. QUALIFICATIONS Bachelor\'s degree, a social worker license from the Massachusetts Board of Registration in Social Work, and at least two years of recent experience working with elders or adults with disabilities; OR a bachelor\'s degree and two years of clinical experience in the care of elders or people with disabilities; OR 2 years of field experience as a case worker in care of elders and or people with disabilities and approved by the MassHealth AFC/ GAFC Program Director and approved by AFC/GAFC Program Manager. Currently licensed \"in good standing\" in MA. Must have a criminal background check. RESPONSIBILITIES/ESSENTIAL FUNCTIONS Receives the intake referral information and prepares paperwork/tools necessary. Obtains all pertinent medical history from patient, family or significant others. Performs the psychosocial evaluation of the support systems available to the patient and documents necessary emergency contacts etc. Participates in the development of the plan of care and discharge planning. Assists patients and their families with personal and environmental difficulties which predispose then toward illness or interfere with obtaining maximum benefits from medical care (counseling members of the family to assisting patients with admission to a nursing home). Performs the skilled visit and documents accordingly. Provides supportive casework designed to restore patients to their optimum level of social adjustment. This includes assisting patients and their families to understand, accept and follow medical recommendations. Assists patients in utilizing the resources of their families and the community at large. Resource utilization may include referring the patients to community resources or acting as an intermediary on behalf of the patients with other health and welfare agencies. Effectively communicates with patient and family. Keeps the patient informed ongoing. Effectively communicates with other disciplines in the case (case conferencing) to effectively and appropriately problem solve as situations arise. Communicates effectively with the Nursing Supervisor scheduled visits and changes to the schedule on a weekly basis. Caseload is self-scheduled, but communication of the clinician?s schedule is essential. Communication with the patient?s physician (verbally and/or in writing) to obtain effective treatment modalities to effect the best means to obtain the desired outcome. Communicates in the case conference sessions to establish best practices for the individual patient?s needs. Submits accurate, complete paperwork at the end of every week. Completes onsite visits to with each member at the qualified setting and completes home safety assessments, review fire and safety procedures Assists in transition and discharge planning Reviews member care logs at a minimum of every 30 days Coordinates Community Services that may be available to the patient to assist in safe home care needs. Participates in the QA Committee process as requested to do so. Acts as a consultant to other agency staff. Participates in the development of in-service programs. Notifies the Agency of emergencies, sickness, and other imminent occurrences that may affect the patient caseload as quickly as possible relative to the event?s occurrence. Submits written time requests 2 weeks or more in advance of planned time off. Other duties as assigned.