Description
Purpose:
The Care Manager assists all current and potential patients in in the Medication Assisted Therapy (MAT) program. They will provide care coordination and conduct assessment that include behavioral, clinical, social, and environmental concerns or needs. They will coordinate programs, services, and facilitate communication between the patient's MAT providers, primary care physicians, drug and etoh clinicians, and community-based services.
Responsibilities:
- Assesses patient's knowledge of their clinical condition and the need for further education
- Collaborates with providers and others in order to obtain initial assessment, treatment planning and aftercare planning for patients.
- Conducts face-to-face patient assessments by visiting the patient in the patient's community, place of residence, or facility. Conduct on-site hospital coordination for discharge planning with facility staff if needed. Coordinate with patient's physicians to ensure follow-up and coordination of care
- Conducts patient assessments identifying behavioral, clinical, social, and environmental concerns and needs.
- Coordinates care and services across the continuum of care with case management, physicians, pharmacy, behavioral health, and other providers or health plan departments as appropriate.
- Develops specific outreach plans for patient's who do not maintain regular contact with their medical or behavioral health provider as recommended contributing to frequent crises, recidivism, and interfering with maximum benefit from available care.
- Ensures that cases are managed and documentation is within established timeframes in accordance with program standards. Participates in case conferences, interagency and provider treatment planning and program meetings.
- Facilitates linkages for patients between MAT services, primary care and behavioral health providers and other social service or provider agencies as needed to develop and coordinate service plans.
- Identifies barriers to care and develops specific integrated plan of care in collaboration with the patient, family, providers and staff.
- Implements appropriate clinical interventions to ensure optimal clinical and quality outcomes for patients.
- Maintains contact with and refers patients to community based case management services as appropriate. Identifies provider issues and recommendations for improvement. Demonstrates knowledge of clinical treatment, case management and community resources.
- Makes referrals and provides expertise regarding community and governmental agencies
Qualifications
- Master's degree in Social Work
- One (1) year of experience working or volunteering in the human services sector.
- Experience working with patients diagnosed with substance use disorders preferred.
- Knowledge of or interest in addiction medicine and substance abuse treatment preferred.
Licensure, Certifications, and Clearances:
- LSW or LCSW preferred
UPMC is an Equal Opportunity Employer/Disability/Veteran
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