Scope: Support elder, at-risk clients with aging care or service needs to promote effective education, self-management support, and timely care and service delivery to achieve optimal quality and financial outcomes. Effectively screen clients and caregivers for well-being, environmental concerns, and social determinants of health. Ability to interpret client needs and translate into a care or service plan that identifies client goals and resources that can help with facilitating client agreed upon ideals of wellness. Coordinate client care and services to improve quality of care by efficiently using resources and enhancing quality, cost-effective outcomes. Ensure that appropriate referrals and connections are being made andScope:
- Support elder, at-risk clients with aging care or service needs to promote effective education, self-management support, and timely care and service delivery to achieve optimal quality and financial outcomes.
- Effectively screen clients and caregivers for well-being, environmental concerns, and social determinants of health.
- Ability to interpret client needs and translate into a care or service plan that identifies client goals and resources that can help with facilitating client agreed upon ideals of wellness.
- Coordinate client care and services to improve quality of care by efficiently using resources and enhancing quality, cost-effective outcomes. Ensure that appropriate referrals and connections are being made and foster engagement with the client's care network and coordination between multiple health and community-based entities.
- Act as an advocate for an individual's healthcare needs and coordinates care to minimize the fragmentation of health care delivery systems.
- Commitment to the pursuit of excellence in improving the health status of the aging community will be essential to drive success.
- Demonstrate comprehension and application of theories related to human behavior, crisis, family systems, personality, change, and adult learning.
- Ensure that professionalism is practiced at all times, including complying with legal and ethical standards, privacy requirements, client advocacy, conflicts of interest, and professional boundaries.
- Participate in meetings and collaborative planning related to population health strategy.
- Participate in developing models of care and support to integrate social and clinical pathways for whole-person care delivery within Knute Nelson and in partnership with other providers and payers.
Key Responsibilities:
- Assist in the implementation of programming.
- Assess and identify client strengths, needs, concerns, and preferences
- Complete client health screenings and evidence-based practice guidelines to identify health, well-being, environmental concerns, and social determinants of health.
- Establish goals and a plan of care or service.
- Implement care and service plans
- Interpret client needs and translate them into client care, that identifies client goals and resources to help facilitate the client's agreed-upon ideals of wellness.
- Manage and monitor the ongoing provision of and need for care and service.
- Coordinate care and services with other healthcare and service provider(s)/organizations
- Assist the technology team and the implementation of technology deployment and usage strategies.
- Act as an advocate for an individual's healthcare needs and coordinate care to minimize the fragmentation of healthcare delivery systems.
- Assist in managing and monitoring the ongoing provision and need for care and service.
- Assist in coordinating care and services with other healthcare and service provider(s)/organizations.
- The duties and responsibilities listed above are representative of the nature and level of work assigned and are not necessarily all-inclusive.
Education and Experience Required:
- Bachelor's degree in social work or related field desired, or five years' experience in care management.
- Knowledge of social work theories and principles; strong assessment, problem-solving, and organizational skills; familiarity with health and social resources; understanding of geriatric care; understanding of the psychosocial implications of acute/chronic illness, mental health, normal/abnormal aging process; and knowledge of basic medical terminology.
- Current certification in care management is preferred or willing to meet the requirement to obtain within a year.
- Should have excellent oral and written communication skills, the ability to work effectively with others and collaborate with the interdisciplinary team.
- Must have general computer skills and must be willing to learn new computer systems.
- Must complete and pass a state-required background study.
- Able to physically perform the duties required by the position.
- Required to have the ability to read, write and speak English well enough to communicate with staff, patients, families, and facilities.
Reports To: Director of Care Managementrecblid ywdtgdvbse0y7dahdkc521genw03w6