Collaborates with PCP & multidisciplinary team to support patient populations with chronic illness, and multiple comorbidites. The care manager - SW understands and adheres to established care management standards that incorporate evidence based protocols, cost effective, and patient focus targeted interventions. Applies Social Work methods to skilled assessment, education, collaboration, and coordination of healthcare and community resources to achieve the following: assist patients to gain self-efficacy/management skills, achieve optimal functional health status, and improve quality of life. Assists patient/families, care team, and systems to achieve high quality, outcomes through telephonic, in person, and/or home visits. Is knowledgeable regarding community and government agencies, support groups, and provides linkages with appropriate TriHealth and community referrals. Providing support services to the PHO and all of its value-based contract members including but not limited to care coordination, home health visits, and counseling. Job Requirements:Bachelor's Degree in Social work, Addictions, Counseling. Licensed Social Worker 3-4 years experience Acute care experience 3-4 years experience Job Responsibilities:Contributes to individualized care for identified patients, focusing on psychosocial assessment and setting goals to meet identified needs. Assess progress toward goals, support evidence based clinical protocols and plan of care, and addresses barriers to progress. Completes required documentation of above. Utilizes registries, reports and tools to identify target populations and patients. Plans for and manages a panel of patients with chronic/complex disease(s); plans interventions appropriate to patients' diagnoses, age, abilities and resources; establishes and implements patient directed learning and supports disease self-management care plan for patient/significant others to enhance therapuetic outcomes. Assesses, plans, implements, monitors, and evaluates delivery of individualized, patient-centered care with the goal of optimizing the patient’s health status through connection with available support systems, community resources, care coordination with necessary specialists, and patient education. Develops plans to address psycho-socio-economic and/or behavioral issues. Works with high risk patients to provide targeted interventions to improve health outcomes. Coordinates care across settings and helps patient/families understand health care options. Promotes patient self-management support with a focus on empowering the patient/family to build capacity for self- care in order to achieve optimal health and independence. Communicates and collaborates with PCP and clinical staff regarding the patient’s psycho-social barriers to health maintenance and assist in coordinating and supporting referrals to indicated services. Interacts with clinical and medical personnel across all hospital inpatient and outpatient service lines to ensure collaboration across care settings and meaningful integration at transition points. Provides end of life discussions and initiates referrals for palliative care and Hospice. Participates in quality improvement initiatives; activities may include data collection, chart review, interdisciplinary collaboration, analysis of patient data and inter-professional staff meetings. Other Job-Related Information: