Partners in Care Foundation

Social Worker

• Provide clinical support and consultation to Care Managers and interdisciplinary care teams across care management programs
• Serve as a clinical resource for chronic disease management, medication monitoring, and complex case review
• Guide staff in member safety and provide consultation and escalation support for high-risk clinical situations
• Ensure clinical services align with evidence-based practices, regulatory standards, and program contracts
• Provide clinical oversight and tracking of comprehensive intake assessments
• Participate in developing, reviewing, and approving patient-centered care plans
• Monitor care plan progress and recommend adjustments based on clinical findings and data
• Collaborate with providers, health plans, hospitals, and community partners to deliver care-plan services
• Coordinate hospital admissions, discharges, and transitions of care
• Perform medication reconciliation and support medication adherence
• Evaluate intervention outcomes and modify care plans and strategies using data
• Participate in quality improvement initiatives, audits, peer reviews, and program evaluations
• Monitor quality improvement measures through documentation review, consultation, and chart audits
• Oversee charting and documentation compliance
• Complete and review care plans, assessments, and case notes using Salesforce, EHRs, or health plan platforms
• Maintain accurate, timely, and compliant SMART-format documentation where applicable
• Ensure confidentiality and HIPAA and regulatory compliance
• Provide staff development training, coaching, and clinical guidance
• Participate in interdisciplinary care team meetings and case conferences
• Attend required trainings, webinars, meetings, and conferences
• Support programming addressing social determinants of health and connections to community organizations
• Promote monthly health promotion topics and materials

Licensed Clinical Social Worker, Clinical Review

Manager

• Evaluate potential clients as total persons and identify functional limitations impeding independent living
• Conduct in-depth assessments and reassessments covering psychosocial, rehabilitation, and environmental concerns
• Refer clients to special consultants for detailed evaluations and recommendations
• Develop care plans, implement services, and conduct follow-up and monitoring
• Identify and develop support systems for clients
• Consult with the Health Practitioner
• Complete case recording and reporting
• Complete client health and psychosocial assessments using relevant information sources
• Participate as an active team member in care planning
• Implement interventions and services using community resources
• Maintain and document regular client contact
• Identify, assess, and respond to crisis situations with appropriate interventions

Social Work Care Manager

Program Assistant

• Process all intakes, referrals and inquiry calls related to waiver and community services
• Assess all inquiries for service that come into the waiver and route appropriately
• Maintain a log of client intakes and waiting list
• Assist with other administrative tasks as assigned
• Provide the best customer service