Manager, Social Support Complex Care

Job Description

We’re unique. You should be, too.

We’re changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy?

We’re different than most primary care providers. We’re rapidly expanding and we need great people to join our team.

The Manager, Social Support, Complex Care is a regional leadership position, accountable for the direction, leadership and support of our Social Complex Care Coordinators, Social Support Supervisors, and Social Support Managers, and all members of the Social Support team in delivering the day-to-day programmatic acute care strategy.

These teams are dedicated to managing our complex care patients in meeting their social and/or behavioral health needs and ensuring their care in all environments is appropriate. This role, in collaboration with the PCP, center staff, and other members of the Complex Care team, provides program management for complex patients to ensure the patient’s progression through the continuum of care in a manner that achieves the desired clinical outcomes and effective resource management.

This role also promotes consistent application of effective processes and social service accountability. More specifically, the incumbent is responsible for their team’s assigned patient case load. Their role is to proactively manage their assigned patients to prevent unnecessary hospital arrivals. In addition, they will be measured by re-admissions related to social needs of the subset of their patients. The Manager, Social Support, Complex Care, works closely with market clinical and operational leadership to support the ongoing improvement of social support operations.

The success of this role is determined by the team’s impact that social needs management has on patients with complex social needs on preventing unnecessary hospital arrivals.

This role may directly manage a regional team that will include multiple areas, social support staff for the programs. As a member of the Complex Care Team, this role is responsible for high-value care across multiple regions, to serve as coach, mentor/trainer to all members of social support complex team, giving guidance in best practices, troubleshooting to optimize the value of care in hospital and community setting.
ESSENTIAL JOB DUTIES/RESPONSIBILITIES:

• Manages a team Social Workers, Licensed Social Workers, Social Support Coordinators, and Behavioral Health Coordinators.
• Actively involved in the full employment cycle of direct reports, including but not limited to participation in the recruitment process, annual performance appraisals, day-to-day oversight of staffing/scheduling needs, problem solving, exit interviews and termination/counseling decisions.
• Provides structure and assures consistent execution of the Social Support Process strategy and execution plan to reach yearly outcomes. Plays a key role in the Case Management Process (CMP), a collaborative model including patients, nurses, social workers, PCPs, specialists, other providers/practitioners and caregivers. Coordinates care with PCPs, Specialists and ancillary teams across the market.
• Advocates for and assists Intensive Community Managers, Post Acute Manager, Acute Care Manager, and all members of the Complex Team with ensuring patients achieve optimal health, access to care and appropriate utilization of resources.
• Consults with, encourages and influences physicians, specialists, and other providers to refer patients to complex social support management for assessment, planning, implementation, coordination, monitoring and evaluation to develop an individualized care plan prior to hospitalization which can result in decreased admissions and hospital sick days. Aids in identifying areas of opportunities at the PCP, center, and market level.
• Serves as the Social and/or Behavioral Health “expert” to support Social Support team members, Complex Care team, and center staff needs for market specific education.
• Facilitates medication reconciliation and adherence education; disease education and coaching; advance…