At Bon Secours Mercy Health, we are dedicated to continually improving health care quality, safety and cost effectiveness. Our hospitals, care sites and clinicians are recognized for clinical and operational excellence. Job Description Provide clinical care management services to identified eligible patients, coordinating care to obtain desired health outcomes, improve self-care abilities, and decrease unnecessary cost of care. Works as a member of Interdisciplinary Team (IDT) along with the Ambulatory Care Manager (ACM) and Care Coordinator to ensure the assigned patient’s individual needs are identified and addressed in a timely manner, Perform standardized comprehensive needs assessment, identifying and addressing barriers to care and aligning patients with available benefits and resources. **Essential Job Functions** Maintain a caseload of patients according to department policies. Identify, enroll and manage patients in program for Complex Case Management. Develop and implement care plans to maximize wellbeing with periodic review and update according to department protocols. Collaborate with ACM, PCPs, Specialists, and Hospitalists to effectively implement a patient-centered care plan. Perform situational and family assessment of social determinants of care and develop goals as part of the comprehensive care plan. Perform patient outreach according to established protocols and document in electronic medical record. Identify, execute, and track needed referrals to care and community resources. Provide resource management to improve care, patient experience and reduce unnecessary cost and utilization: right care, right place, and right time. Assist patient in advanced care planning to complete Advanced Directives. Document all communications with patient and/or care team in electronic medical record. Perform coordination of services for disabled status and/or facilitate placement in post-acute facility for rehabilitation or long term care. Act as patient advocate to address primary physical and socioeconomic needs and link patient to appropriate community resources and services. This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job related duties as required by their supervisor, subject to reasonable accommodation. **Education Qualifications** - Required Minimum Education: Bachelor’s Degree, Social Work Preferred Education: Master’s Degree, Social Work **Licensing/ Certification** - Licensure/Certification Required: Master’s Degree or Licensure as required by state of practice Licensure/Certification Preferred: Case Management certification, LSW or LCSW **Minimum Qualifications** 2-3 years acute care, home health or case management experience Other Knowledge, Skills and Abilities Required Excellent interpersonal communication and negotiation skills. Strong analytical, data management and computer skills. Demonstrate basic knowledge of healthcare and health education across the lifespan in a practice health setting. Ability to work with individuals, groups and families. Familiarity and knowledge of Community Resources. Flexibility to work non- traditional hours. Works well in a Team Setting. Personal computer skills. Experience with database entry, EMR documentation, Power Point preferred and basic Excel skills. Highly organized and detail oriented. Accepts responsibility and follows through on projects and activities Other Knowledge, Skills and Abilities Preferred Demonstrated success in improving the health of a distinct population of patients in the ambulatory or community setting Many of our opportunities reward* your hard work with: Comprehensive, affordable medical, dental and vision plans Prescription drug coverage Flexible spending accounts Life insurance w/AD&D Employer contributions to retirement savings plan when eligible Paid time off Educational Assistance And much more *Benefits offerings vary according to employment status All applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, sexual orientation, gender identity, age, genetic information, or protected veteran status, and will not be discriminated against on the basis of disability. If you'd like to view a copy of the affirmative action plan or policy statement for Mercy Health – Youngstown, Ohio or Bon Secours – Franklin, Virginia; Petersburg, Virginia; and Emporia, Virginia, which are Affirmative Action and Equal Opportunity Employers, please email recruitment@mercy.com . If you are an individual with a disability and would like to request a reasonable accommodation as part of the employment selection process, please contact The Talent Acquisition Team at recruitment@mercy.com