About the role

  • Care Navigator engaging high-risk patients, implementing interventions and coordinating care efforts in a hybrid role for CenterWell Senior Primary Care. Requires MSW and LMSW in the Las Vegas area.

Responsibilities

  • Conduct Transitions of Care Management for a subset of the patient population, including ER and hospital follow ups
  • Provide triage guidance and supportive consultation to other team members, handling escalated complex cases
  • Develop care plans leveraging 5Ms Geriatric best practice framework
  • Develop a wholistic view of patient needs related to Social Determinants of Health
  • Identify existing barriers to engagement with necessary resources and supports
  • Provide education around maintenance of chronic health conditions, as well as available options for behavioral care and social support
  • Serve as liaison between the patient and the direct care providers, assisting in navigating both internal and external systems
  • Initiate care planning and subsequent action steps for high-risk members, coordinating with interdisciplinary team
  • Supporting patients’ self-determination, motivate patients to meet the health goals they have identified
  • Refer patient to necessary services and supports
  • Lead Interdisciplinary Team Meetings when indicated
  • Assess patient’s family system, and conduct family meetings with patient and family when needed
  • Participate in creation and facilitation of team training content
  • Conduct group psychoeducation and support groups within the Center
  • Perform all other duties and responsibilities as required
  • Participate in and lead interdisciplinary review of and coordination around complex patients
  • Maintain patient confidentiality in accordance with HIPAA
  • Document patient encounters in medical record system in a timely manner

Requirements

  • Master's in Social Work (MSW)
  • Licensed Master Social Worker in Nevada (LMSW)
  • Minimum of 4 years of experience working in healthcare services and navigating community-based resources
  • Familiarity with state Medicaid guidelines and application processes
  • Experience working with patients with behavioral health conditions and substance use disorders
  • Prior experience conducting home visits and knowledge of field safety practices

Benefits

  • Health benefits effective day 1
  • Paid time off, holidays, volunteer time and jury duty pay
  • Recognition pay
  • 401(k) retirement savings plan with employer match
  • Tuition assistance
  • Scholarships for eligible dependents

Job title

LMSW Care/Case Manager

Job type

Experience level

Mid levelSenior

Salary

$65,000 - $88,600 per year

Degree requirement

No Education Requirement

Location requirements

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