Care Manager, Adult Services - Social Worker

Care Manager (Social Worker)

The Care Manager (Social Worker) is responsible for delivering clinically and psychosocially informed, person-centered care management services to Medicaid members with complex physical, behavioral health, and social determinants of health.

This role conducts comprehensive clinical and/or biopsychosocial assessments, manages Transitions of Care (TOC) and other high-risk outreach, develops individualized care plans, and supports members through care coordination, system navigation, and condition management.

The Care Manager is a licensed professional who collaborates with interdisciplinary and multi-agency teams to ensure coordinated, high-quality care that improves member engagement, stability, health outcomes, and reduces avoidable utilization.

This role requires comfort with outbound outreach, including cold-call engagement of hard-to-reach members, to meet program productivity standards and contractual performance requirements.

Essential duties include:

• Perform comprehensive clinical and/or psychosocial assessments for assigned high-risk, medically complex, and high-barrier members.
• Develop, implement, and update individualized care plans addressing medical, behavioral health, psychosocial, and environmental needs.
• Manage transitions of care following hospitalization, emergency department utilization, facility stays, behavioral health transitions, or other acute episodes.
• Complete all required follow-up for transition-of-care and assigned populations within established timelines.
• Conduct ongoing care management, monitoring, and coordination for designated members.
• Identify and address barriers affecting adherence, recovery, stabilization, and follow-up, including housing, transportation, food insecurity, caregiver support, financial strain, behavioral health, and substance use concerns.
• Coordinate care with PCPs, specialists, behavioral health providers, facilities, caregivers, interdisciplinary teams, and community agencies.
• Connect patients to community resources, social services, behavioral health resources, and support programs.
• Provide patient and caregiver education related to disease management, self-management, care navigation, resource access, and next steps in care.
• Utilize motivational interviewing, engagement strategies, and de-escalation techniques to support member participation and goal attainment.
• Escalate urgent clinical, psychosocial, crisis, safety, or member-protection concerns appropriately.
• Collaborate with interdisciplinary teams to support integrated, person-centered care delivery.
• Maintain timely, accurate, and compliant documentation across assessments, care plans, outreach, follow-up, and coordination activities.
• Maintains a high level of confidentiality and ensures compliance with HIPAA regulations.
• Assist with planning, coordinating, and representing the organization at community events designed to retain existing members and generate awareness among prospective members.
• Deliver educational presentations to existing and prospective members at community events, clinics, and partner sites: evening and weekend availability is required to support scheduled events and community programming.
• Other duties as assigned

Populations served include:

• Medicaid and designated high-risk, complex member populations
• Member requiring transition-of-care support
• Member with repeated utilization, worsening acuity, or chronic-condition instability
• Member with psychosocial, behavioral health, environmental, or social determinants of health barriers
• Member requiring community-resource linkage and psychosocial intervention
• Other assigned populations as applicable

Education:

Active Master of Social Work (MSW) with active applicable licensure in good standing.

Must be licensed in the state where the assigned population is served.

Experience:

1+ years of experience in care management, care coordination, case management, behavioral health, social work, utilization management, transitional care, or related experience.

Experience working with high-risk, medically complex, behavioral health, or psychosocially complex populations.

Experience supporting transitions of care.

Preferred experience:

• Experience with Medicare Advantage, Medicaid, DSNP, and/or CSNP populations.
• Experience in value-based care, managed care, or population health.
• Case management certification or related credential.
• Bilingual capability, where relevant to market needs

Knowledge, Skills, Abilities:

• Knowledge of community resources and behavioral health…