Description Job Summary
To provide advanced social work services for the Community Alternatives Program for Disabled Adults and Children and assistance in locating, coordinating, monitoring, and assisting in determining eligibility for social, medical, financial, and other services to meet the needs of the Community Alternative Program patients.
Core Responsibilities
Assessment and Evaluation Assess which patients need social intervention and referral Conducts the initial pre-screening and initial assessment of the patient and family Evaluates needs and resources of the patient/family and need for other community services Planning Develops social work portion of the plan of care to ensure the health, safety, and well-being of patients Reviews and updates the plan of care at least every twelve months or as the patient status requires Assists the patient/family in understanding the plan of care and making informed choices Utilizes appropriate community resources planning as well as initiates appropriate referrals Provides counseling and emotional support to strengthen patient/family support system Implementation and Follow-up Collaborates with the disciplines within the agency to ensure a comprehensive approach to patient care Provides continuous evaluation and monitoring of services through documentation and consultation Participates in appropriate interagency conferences Serves as a liaison between patients and provider agencies Performs on-going systematic patient assessment through monthly telephone calls and home visits and documents according to policy Evaluates and documents effectiveness of care based on observable responses of patient, recommending or instituting changes needed to attain identified patient outcomes Provides monthly case management for assigned patients Documentation Completes all required records per agency policy and the State CAP manual Documents pertinent changes in patient’s condition during contacts with patients, family, and other provider agencies Completes a discharge summary when CAP services are completed. This summary should review services provided, patient’s response and status at discharge Maintains medical record for each patient with current documentation of patient status, service changes and referrals Maintain Case Management documentation within the E-CAP system, review In-Home Aide documentation, review re-certifications, and supply billing for proper billing codes and compliance according to CAP guidelines Professional Development Completes requirements for continuing education per year as established by agency policies and procedures Completes State mandated training as required; Completes E-CAP updates as required With the Community Alternatives Program Director, develops and achieves professional goals and revises accordingly to reflect the dynamic nature of the unit. Evaluates the goals annually Completes mandatory organization education as per policy
Requirements
Skills and Knowledge: Working knowledge of basic social work principles, techniques, and practices and their application to specific casework, group work and community problems Knowledge of governmental and private organizations and resources in the community Strong organizational, communication, listening, and assessment skills Ability to travel as needed to other office locations
Education/Training
1. Bachelor’s degree in social work from an accredited school of social work and one (1) year of directly related community experience (preferably case management) in the health or medical field directly related to home care, long-term care, or personal care and the completion of an NC Medicaid certified training program within 90 calendar days of employment; OR 2. Bachelor’s degree in a human services or equivalent field from an accredited college or university with two or more years of community experience (preferably case management) in the health or medical field directly related to home care, long-term care, or personal care and the completion of an NC Medicaid certified training program within 90 calendar days; OR 3. Bachelor’s degree in a non-human services field from an accredited college or university with two or more years of community experience (preferably case management) in the health or medical field directly related to home care, long-term care, or personal care and the completion of an NC Medicaid certified training program within 90 calendar days; OR 4. Nurse who holds a current North Carolina license with two (2) year or four (4) year degrees and one (1) year case management in home care, long-term care, personal care, or related work experience and the completion of an NC Medicaid-certified training program within 90 calendar days; OR 5. An individual with a bachelor’s degree or who holds a nursing license as described above, without the number of years of experience, may be designated as an apprentice or a trainee and shall be hired to act in the role of case manager. The supervisor of the case manager shall provide direct supervision and approve all waiver workflow documentation and tasks.
Physical/Environmental Demands
Sitting for various lengths of time while operating the computer with frequent stretching, talking, hearing, bending, and reaching. At times, it may require moving supplies and /or equipment from vehicle to patient’s residence. Must be able to walk up stairs in patient residences. May be exposed to dangerous animals and other situations that may present a potential threat to personal safety
The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this job. They are not intended to be an exhaustive list of all responsibilities, duties and skills required of the position. All employees may have other duties assigned at any time.
