*This position will be doing home and facility visits in Hagerstown 4-5 days/week*

Summary/Position Objectives:

The Social Worker will support the Transition of Care (ToC) Team with the management of difficult social needs at discharge for identified high-risk complex members to allow for continuity of care starting in the facility setting and allow for appropriate transition of care. In this role, the Social Worker will contact the Facility Case Manager and the Member while in the Hospital or a Skilled Nursing setting and begin to facilitate the discharge to the next appropriate level of care. The Social Worker will work directly with Facility Case Managers and MPC members to address social barriers and provide care management through a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet members’ health needs through communication and available resources, while promoting quality cost-effective outcomes. The social worker will assist MPC Members to transition to the most independent living situation possible; ensures consistent care along the entire health care continuum by assessing and closely monitoring members’ needs and status.

About Maryland Care Management, Inc. (MCMI)

Maryland Care Management, Inc. (MCMI) manages Maryland Physician Care’s (MPC) statewide provider network of hospitals and physicians. Maryland Physicians Care has been providing services to the HealthChoice Medicaid populations since 1996, and we are proud of our footprint in the community. With over 230,000 members, MPC consistently has been one of MD’s largest Medicaid-managed care organizations.

Why join us?

MCMI recognizes the importance of flexibility and offers multiple work arrangements. Along with competitive pay, we offer excellent benefits (medical, dental, and vision plans, 100% employer Term Life Insurance, Short and Long-Term Disability, 401k Employer Match up to 4%) as well as 20 days of PTO, and tuition assistance/professional development plans.

Your future colleagues at MCMI are welcoming, friendly, and eager to help each other succeed. We are committed to Diversity, Equity, and Inclusion, providing organizational-wide social opportunities, and constantly improving our ongoing efforts to positively impact our members’ lives.

What You’ll Do:

• Evaluate members based on their needs and limitations based on referrals.
• Will work directly with the Hospital/SNF case management staff to assist with the coordination of care and discharge plans for identified members.
• Will collaborate directly with members and their families to build a rapport to assist with discharge needs as appropriate.
• Address member concerns and goals while maintaining constant communication with the member.
• Utilizes clinical judgement to assess members, prioritizing emerging issues to maintain a member-centric approach.
• Collaborates with interdisciplinary care team at the facilities to support member health goals via conference calls, rounds, and consultation, which may include face-to-face meetings.
• Complete assessments to better understand the Social Determinants of health and social issues impacting member care goals.
• Utilizes problem-solving skills to research and identify community resources and coordinate a referral mechanism.
• Plans specific objectives, goals, and actions designed to meet the members’ needs as identified in the assessment process that are action-oriented, time-specific, and cost-effective.
• Implements specific activities and/or interventions that lead to accomplishing the goals outlined in the plan of care.
• Develop trusting relationships with members by providing support and advocacy to help achieve health goals.
• Monitors care management activities, services, and members’ responses to interventions, to determine the effectiveness of the plan of care and the utilization of services.
• Evaluate the effectiveness of the plan of care in reaching desired outcomes and goals; makes modifications or changes in the plan of care as needed.
• Make connections with members through visits to the hospital, home, and community via face-to-face, telephonic and/or video conferencing.
• Participates in outreach activities to promote knowledge of the program and its services and to coordinate program activities with outside community agencies and health care providers.
• Work with the MPC Case Management Team for an appropriate transition of care.

Secondary Functions:

• Observe confidentiality of member records in accordance with MPC policies and procedures.
• Possession of a valid MD State Driver’s License.

Knowledge and Skills:

• Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.
• Knowledge of community agencies and resources.
• Working knowledge of multi-system outreach programs related to health care delivery, clinical education, and health-related services.
• Ability to plan, implement, and evaluate individual member care plans.
• Knowledge of change management, behavioral change management, transportation/food/safety resources.

Education and Work Experience:

• Master’s degree in social work.+
• Maryland state LMSW/LCSW or LCSW-C licensure.
• 3+ years of experience managing and integrating the social needs of members.
• 3 years of experience in a community setting.
• Knowledge of government-managed care programs preferred.

EEOC Statement:

Following applicable federal, state, and local laws, MCMI prohibits discrimination in employment based on race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age, disability, genetic information, or any other characteristic protected by law. This commitment extends to all aspects of employment, including hiring, promotion, compensation, benefits, training, social and recreational programs, and all other conditions and privileges of employment.

As a healthcare organization, we recognize the vital importance of inclusivity in delivering quality care to our patients. We strive to foster an environment where individuals of all backgrounds feel respected, valued, and supported. We aim to better comprehend the unique needs of our patients and provide healthcare services that are culturally competent and sensitive.

We encourage candidates from all backgrounds to apply and join us in our mission to provide compassionate and inclusive healthcare. We believe that a diverse workforce enriches our organization and allows us to better understand, connect with, and serve our diverse patient population.