About The Role

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Job Description

OVERVIEW OF POSITION

The Care Manager (Social Worker) is responsible for delivering clinically and psychosocially informed, person-centered care management services to Medicaid members with complex physical, behavioral health, and social determinants of health.

This role conducts comprehensive clinical and/or biopsychosocial assessments, manages Transitions of Care (TOC) and other high-risk outreach, develops individualized care plans, and supports members through care coordination, system navigation, and condition management.

The Care Manager is a licensed professional who collaborates with interdisciplinary and multi-agency teams to ensure coordinated, high-quality care that improves member engagement, stability, health outcomes, and reduces avoidable utilization.

This role requires comfort with outbound outreach, including cold-call engagement of hard-to-reach members, to meet program productivity standards and contractual performance requirements.

ESSENTIAL DUTIES

Perform comprehensive clinical and/or psychosocial assessments for assigned high-risk, medically complex, and high-barrier members .
Develop, implement, and update individualized care plans addressing medical, behavioral health, psychosocial, and environmental needs.
Manage transitions of care following hospitalization, emergency department utilization, facility stays, behavioral health transitions, or other acute episodes.
Complete all required follow-up for transition-of-care and assigned populations within established timelines.
Conduct ongoing care management, monitoring, and coordination for designated members .
Identify and address barriers affecting adherence, recovery, stabilization, and follow-up, including housing, transportation, food insecurity, caregiver support, financial strain, behavioral health, and substance use concerns.
Coordinate care with PCPs, specialists, behavioral health providers, facilities, caregivers, interdisciplinary teams, and community agencies.
Connect patients to community resources, social services, behavioral health resources, and support programs.
Provide patient and caregiver education related to disease management, self-management, care navigation, resource access, and next steps in care.
Utilize motivational interviewing, engagement strategies, and de-escalation techniques to support member participation and goal attainment.
Escalate urgent clinical, psychosocial, crisis, safety, or member-protection concerns appropriately.
Collaborate with interdisciplinary teams to support integrated, person-centered care delivery.
Maintain timely, accurate, and compliant documentation across assessments, care plans, outreach, follow-up, and coordination activities.
Maintains a high level of confidentiality and ensures compliance with HIPAA regulations
Assist with planning, coordinating, and representing the organization at community events designed to retain existing members and generate awareness among prospective members.
Deliver educational presentations to existing and prospective members at community events, clinics, and partner sites: evening and weekend availability is required to support scheduled events and community programming.
Other duties as assigned

POPULATION SERVED

Medicaid and designated high-risk, complex member populations
Member requiring transition-of-care support
Member with repeated utilization, worsening acuity, or chronic-condition instability
Member with psychosocial, behavioral health, environmental, or social determinants of health barriers
Member requiring community-resource linkage and psychosocial intervention
Other assigned populations as applicable

EDUCATION

Active Master of Social Work (MSW) with active applicable licensure in good standing.
Must be licensed in the state where the assigned population is served.

EXPERIENCE

1+ years of experience in care management, care coordination, case management, behavioral health, social work, utilization management, transitional care, or related experience.
Experience working with high-risk, medically complex, behavioral health, or psychosocially complex populations.
Experience supporting transitions of care.

Preferred experience

Experience with Medicare Advantage, Medicaid, DSNP, and/or CSNP populations.
Experience in value-based care, managed care, or population health.
Case management certification or related credential.
Bilingual capability, where relevant to market needs

KNOWLEDGE, SKILLS, ABILITIES

Knowledge of community resources and behavioral health supports.
Proficiency with EMR and care-management documentation systems.
Complete assessments, care plans, outreach, and follow-up activities within required timelines.
Complete transition-of-care follow-up within organizationally defined timeframes.
Maintain timely and compliant documentation across all care management activities.
Meet expectations related to care-plan completion, case progression, barrier resolution, and member engagement.
Escalate urgent or deteriorating clinical, psychosocial, or safety concerns promptly.
Meet role-specific LPIs/productivity expectations and delegated responsibilities.
Strong clinical and/or psychosocial assessment and intervention skills
Strong care planning and coordination capability
Knowledge of behavioral health, community-resource systems, and social determinants of health
Strong crisis support and de-escalation ability
Ability to manage medically complex and high-barrier patients across settings
Strong communication and collaboration with providers, caregivers, and interdisciplinary teams
Motivational interviewing and patient engagement skills
Strong documentation, follow-through, and compliance discipline
Ability to prioritize risk and intervene appropriately
Ability to manage sensitive and complex cases professionally
Home office, that is HIPAA compliant for all remote or telecommuting positions as outlined by the company policies and procedures

Salary Range

Salary Range: $63,502.40- $81,000
Additional Compensation: Eligible for annual bonus based on individual and/or company performance.
Benefits: Includes medical, dental, and vision insurance; 401(k); paid time off (PTO); and Employee Assistance Program (EAP)
Application Deadline: Open until filled. Applications will be reviewed on a rolling basis.
How to Apply: Apply via careers page at https://alpinephysicians.wd1.myworkdayjobs.com/external