Title: Community Care Team HOME Care Manager Social Worker Territory: Mid coast/Southern Maine & Martins Point Health Care What You’ll Do: + Care Manager Social Worker will, in collaboration with the primary care practice, coordinate services using a systematic and cost-effective approach to provide patient-centered care for a defined population. + The Care Manager will engage the patient to reduce unnecessary health care services and improve their overall health and well-being. A specialized focus on housing support will be provided to HOME enrolled patients. + Care Manager to work with each practice to assess the gaps in care coordination as well as patients’ access to and utilization of community supports. + The Care manager will need to collaborate with designated physician practices and community partners to determine the best model for addressing the needs of the most complex patients. + Work with patients with complex emotional-social issues and mental health concerns. + Work with CCT, primary care provider, and Mainecare to identify recipients who are most likely to benefit from care management intervention and agree to participate. + Care manager may make patient visits prior to hospital discharge, in the primary care practice, in the home or public setting. What You’ll Bring: + Current Social Worker licensure or conditional Social Work licensure in the State of Maine. + Must have a reliable automobile. + Must have current Maine driver’s license. + Independent malpractice insurance strongly advised. + Evidence of automobile insurance. + Must submit current licensure every two years to Human Resources Dept., before expiration date. + Must be proficient in use of computers and adept at learning new programs.