Clinical - Program Specialist Social Worker

Job Description:

Job Title: Program Specialist 1 Social Worker

Location: Remote (Mcallen Texas 78501 Possibility to train from office for first 12 weeks)

Duration: 6 months (Possible extension)

Shift: MonFri 8 am 5 pm

Job Summary:

• Conduct screening and risk assessment interventions per program guidelines.
• Assist with nonmedical aspects of the members care including referrals to community resources.

Walk me through the daytoday responsibilities of this the role and a description of the project (Outside of Workday JD):

• Telehealth assessments
• Review assessments & service plans (vendor or internal assessments)
• Follow up on pending assessment findings clarify DX reported abnormals requested referrals etc.
• Hospital discharges follow up
• MN denials
  • Research community resources.
• 2065D approval/denials
  • Update LTSS
  • Terminate LTSS waiver service authorizations.
  • Provide community resources.
  • Instruct member on appeal process and level change.
• ISP updates (internal) 17003 obtain verbal approval and update form update 17002 with waiver items.
• Initiate LTSS/acute services (create authorization request template)
• Research complaints and provide updates to managers for complaint responses.
• Escalations
  • MSC call backs.
• CDS review
• Acute UM denials to include PT denial request for more information.
• Create clinical reviews/IRTs
• CIC CIS without MNLOC completion.
• Fair hearing assistance as needed.
• Determine MN for post assessment identified items.
• Dental nursing vision verify service utilization hearing 90 day MHM 28 day follow ups.
  • Verify all services have been started.
  • Follow up on all non DME identified needs.
• Send required referrals for new services/items identified except DME.
• Submit DME tasks for newly identified DME items.

Describe the performance expectations/metrics for this individual and their team:

• Review monthly audits and weekly calls to ensure we are meeting contractual requirements

Job Responsibilities:

• Healthy Opportunities (HOP) Eligibility & Enrollments Benefits Eligibility Screenings Cold Calls Assistance in phone queue.
• Identify special needs members through the completion of health screens and other resources.
• Work with community outreach/member advocates to coordinate member care.
• Educate providers and community resources on program components and available support services.
• Educate members with special needs to foster compliance with program and positively impact outcomes.
• Conduct site visits as appropriate for programs and provide support to other special programs.
• Develop and modify care plans in conjunction with members members family and managing physician.
• Development of plan specific literature and education materials in conjunction with medical director and corporate oversight

Minimum Qualification:

• Bachelor/masters in social work.
• Proficient with excel/word.
• Experienced MSW/SW in a healthcare/community setting.
• Community work experience with closing SDoH needs.