Social Worker Care Manager (Hybrid - Frederick, MD)

Job Description

Job Description

About Us

Ennoble Care is a mobile primary care, palliative care, and hospice service provider with patients in New York, New Jersey, Maryland, DC, Virginia, Oklahoma, Kansas, Pennsylvania, and Georgia. Ennoble Care's clinicians go to the home of the patient, providing continuum of care for those with chronic conditions and limited mobility. Ennoble Care offers a variety of programs including, remote patient monitoring, behavioral health management, and chronic care management, to ensure that our patients receive the highest quality of care by a team they know and trust. We seek individuals who are driven to make a difference and embody our motto, "To Care is an Honor." Join Ennoble Care today!

Ennoble Care is seeking an experienced Full-time Social Worker Care Manager (Hybrid) to service our patients within and around the Frederick, MD area. This position will be primarily remote with occasional travel to patients homes / facilities.

RESPONSIBILITIES

• Support the mental and physical health care of patients on an assigned patient caseload.
• Screen and assess patients for common mental health and substance abuse disorders. Facilitate patient engagement and follow-up care.
• Provide patient education about common mental health and substance abuse disorders and the available treatment options.
• Systematically track treatment response and monitor patients (in person or by telephone) for changes in clinical symptoms and treatment side effects or complications.
• Support psychotropic medication management by consulting with the behavioral health consultant and then communicating with the primary care provider assigned.
• Provide brief behavioral interventions using evidence-based techniques such as behavioral activation, problem-solving treatment, motivational interviewing, or other treatments as appropriate.
• Provide or facilitate in-clinic or outside referrals to evidence-based psychosocial treatments (e.g. problem-solving treatment or behavioral activation) as clinically indicated.
• Participate in regularly scheduled (usually weekly) caseload consultation with the psychiatric consultant and communicate resulting treatment recommendations to the patient's medical provider. Consultations will focus on patients new to the caseload and those who are not improving as expected under the current treatment plan. Case reviews may be conducted by telephone, video, or in person.
• Track patient follow up and clinical outcomes using a registry. Document in-person and telephone encounters in the registry and use the system to identify and re-engage patients. Registry functions can be accomplished through an EHR build, on a spreadsheet used in conjunction with an EHR, or can be built into a stand-alone clinical management tracking system that may or may not be linked to an EHR.
• Document patient progress and treatment recommendations in EHR and other required systems so as to be shared with medical providers, psychiatric consultant, and other treating providers.
• Facilitate treatment plan changes for patients who are not improving as expected in consultation with the medical provider and the psychiatric consultant and who may need more intensive or more specialized mental health care.
• Facilitate referrals for clinically indicated services outside of the organization (e.g., social services such as housing assistance, vocational rehabilitation, mental health specialty care, substance abuse treatment).
• Develop and complete relapse prevention self-management plan with patients who have achieved their treatment goals and are soon to be discharged from the caseload.
• Be comfortable utilizing Excel and Word and completing assessments and productivity trackers daily.
• Time-management skills are a must and the BHCM needs to be able to manage their day effectively through calendars and the EMR system.
• This role is PRIMARILY telephonic, however in person visits are done and the BHCM has to be comfortable completing them both ways.

Qualifications :

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Full-time employees qualify for the following benefits :

All employees qualify for these benefits :

Ennoble Care is an Equal Opportunity Employer, committed to hiring the best team possible, and does not discriminate against protected characteristics including but not limited to - race, age, sexual orientation, gender identity and expression, national origin, religion, disability, and veteran status.