The Care Manager, Social Worker is responsible for identifying and understanding community-based resources and connecting patients with these resources as needed. Previous experience with epic and hospice and palliative services preferred. Our patient population is primarily Medicaid-insured and underinsured, often facing barriers such as housing instability, food insecurity, transportation challenges, and untreated mental health conditions. The Social Worker plays a critical role in improving health outcomes by addressing these social determinants of health. You will work side-by-side with primary care providers, nurses, and care coordinators to deliver whole-person, patient-centered care. • Full Time/Benefit Eligible • Monday - Friday - 8:00am-4:30pm, hybrid • Columbus, OH ESSENTIAL FUNCTIONS AND RESPONSIBILITIES: • Complete patient assessments to evaluate all social, psychological, or environmental needs related to the impact of admission, diagnosis, treatment, or discharge. • Provide patient/caregiver with education, information, and referral services. Provide patient/caregiver with relevant information about medical illness, behavioral health, insurance coverage, support, and community services. • Develop plan of care for patients in collaboration with the primary care team. Document in the medical record as indicated and designated case management tool accurately. • Provide ongoing communication between the patient and health care team to ensure improved patient outcomes and high quality of patient care. Conduct end-of-life discussions with patient/family, as needed. • Facilitate referrals to other disciplines and internal health and community based programs as needed to improve patient outcomes. Coordinate and participate in interdisciplinary patient/caregiver conferences. • Participate in departmental process improvement initiatives, work on special projects as needed and attend all departmental meetings. • Serve as an advocate and resource for the patient/caregiver. • Provide temporary case management to a specified case load. Qualifications A. Experience, Education, Licensures & Certifications • Required: Five years or more clinical and care management experience in hospital, home health/hospice, or managed care setting • Required: Licensed Social Worker in the state of Ohio • Required: Active Ohio driver's license with the ability to travel throughout COPC's service area as needed • Required: Previous experience working with Medicaid patients; knowledge of Medicaid rules and regulations • Preferred: Master's degree in Social Work • Preferred: Epic EHR system experience B. Knowledge, Skills & Abilities • Proficient in computer software and usage including but not limited to Microsoft Outlook and Microsoft Excel • Knowledge of community resources and behavioral needs for adult population • Knowledge of trends in healthcare, managed care, Medicaid, case management, medical management and quality improvement • Demonstrate awareness and ability to work alongside diverse cultures and patient populations • Ability to create positive working relationships with physicians and other members of the health care team • Ability to demonstrate work toward the progress of patient- centered goals • Ability to adapt to changing environment • Ability to work independently and within a team environment with minimal supervision • Excellent negotiation and advanced conflict resolution skills • Strong analytical, organizational, and time management skills • Strong written and verbal communication skills; ability to communicate effectively in stressful situations • Self-disciplined, energetic, passionate, and innovative • Decision making/problem solving and training/teaching skills • Critical and ‘systems' thinker with strong attention to detail