Social Work Case Manager (LMSW) Maryland Medicaid
Core
Coordinate post-acute care transitions for Medicaid members to reduce hospital readmissions and ensure smooth discharge from hospital to home or community settings.
Role type
Licensed Social Work Case Manager (Post-Acute Discharge Coordination)
Builds
Post-discharge care plans and community service connections for Medicaid members
Domain
Healthcare / Medicaid / Post-Acute Care
Deliverable
client delivery
Required skills
Case management, discharge planning, psychosocial intervention, care coordination, referral management, chronic illness management
Preferred skills
Medicaid population experience, complex condition care coordination, bilingual/multi-language skills
Technologies
Care Management (CM) programs, digital health solutions
Responsibilities
Conduct comprehensive needs assessments for members and caregivers, develop and coordinate detailed discharge plans, initiate referrals to address social determinants of health, collaborate with hospital care coordinators and external providers, provide ongoing follow-up support for evolving care needs
Seniority
Mid-level, licensed professional