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General Statement of Duties A. Primary Purpose of Organizational Unit To provide Care Management services to Nash County residents to improve outcomes and reduce medical costs. The Nash County Health Department is a public health agency established under the General Statutes of North Carolina and provides services for all residents of Nash County.

These services are carried out in conjunction with the North Carolina DHHS. B. Primary Purpose of Position To provide the delivery of pregnancy care management services that improve birth outcomes in the North Carolina Medicaid population and thereby reduce costs.

The pregnancy care managers, working with DHB network, provide a variety of services in the form of population management and direct pregnancy care management. C. Work Schedule Monday through Friday, 8:00 am - 5:00 pm.

If after hours maternity clinic is in operation at the Health Department, employee will rotate with CMHRP staff to cover staffing for Social Work services. Social Worker may have to work emergency shelter or special clinics as necessary. D.

Change in Responsibilities or Organizational Relationship The Nash County Health Department is contracted with various Prepaid Health Plans to provide Care Management services to targeted population. Essential Duties and Tasks A. 1.

General Description Job Description: Social Worker II - CMHRP Utilize targeted data and referrals to identify patients who may benefit from pregnancy care management. Pregnant and postpartum women with priority risks are identified and engaged. Once this occurs, clear documentation of the pregnancy assessment, conditions/needs, interventions, goals and other pregnancy care management activities are performed.

Complete all documentation online in Virtual Health. 2. Recruitment and Initiation of a.

Referrals for pregnancy care management come from multiple sources. The primary source for patient identification is the completion of Initial Risk Screening forms by Pregnancy Medical Home Practices. Other referral sources include hospitals, other community agencies and self-referral.

b. Patients with positive risk screens such as hospital utilization (emergency department, labor & delivery triage, hospital admission, chronic health conditions) would benefit from pregnancy care management. c.

Maintain on-going contact with local physicians and community agencies that provide medical care and services to pregnant and postpartum women in order to promote referrals for Care Management for High Risk Pregnancy. d. Assist in identification of pregnant and postpartum women who potentially meet the target population criteria.

3. Care Management Job Functions and Responsibilities a. Serve as the Care Manager for Medicaid eligible pregnant and postpartum women residing in Nash County following State DHB, PHP and DHHS guidelines and performing at least the following activities: Outreach Population identification Assessment and risk stratification Interventions based on plan of care and referrals as indicated Integration with health care providers (Medical Home) Collaboration with the local Prepaid Health Plan network Enter required data in Virtual Health b.

Provide care management services in accordance with the approach outlined in the Care Management for High Risk Pregnancy Standardized Plan. c. Facilitate client/family in accessing appropriate services within the community.

d. Assesses psychosocial, nutritional (WIC referral), medical, educational and financial needs using Pregnancy Home Risk Screening forms and Comprehensive Needs Assessment. e.

Counsels regarding importance of early prenatal and continuous prenatal care. Counsels patients on the importance of keeping all appointments and following medical/nursing recommendations. g.

Maintain good rapport with other agency staff as well as other service providers in the community. h. Serves as liaison with local physicians, Home Health, local hospital, Department of Social Services, and Regional High Risk OB clinic.

4. Additional Duties/Responsibilities for CMHRP a. Continuously update knowledge and skills in the area of Maternal, Child Health and Public Health.

Job Description: Social Worker II - CMHRP b. Serve on appropriate committees which focus on infant mortality and other issues which affect clients. (Supervisor approval is required) c.

Attend trainings, educational activities, and monthly staff meetings. d. Be an active member of the Care Management Team.

Participate in monthly meetings with CMHRP staff. Responsibility is to provide input in ongoing caseload to ensure quality and continuity of care. e.

Participate in disaster services as required. Assist with department wide community activities (ex. Flu clinics, health fairs) as needed.

f. Represent the Agency in court only when subpoenaed to testify. g.

Other duties as assigned by the Social Work Supervisor and/or Health Director. B. Major Activities 90% Case Management These activities include: assessing the patient, family and environment; developing a care plan; counseling and education; referral and follow-up; monitoring needs; and serving as an advocate for the patient.

10% Resource Development/Community Liaison Serves as a liaison with other service providers and attends job related workshops when appropriate. Promotes CMHRP by attending speaking engagements upon invitation. C.

Guides, Regulations, Policies and References Used by Employee: . Care Management for High Risk Pregnancy Standardized Plan . Local Health Department Policies, Procedures and Standing Orders .

Work under North Carolina Public Law - Confidential 130-A143, Abuse or Neglect 7A-543, Treatment of Minors 90-21.5 . Medicaid Guidelines D. Variety and Purpose of Personal Contacts: Works directly with clients of all social, ethnic and economic groups

Clients often suffer drug or alcohol addiction, emotional or physical illness, as well as having many other unmet needs. The CMHRP CM must work closely with these individuals advocating on their behalf. Interaction with outside providers for the purpose of accessing needed services and resources as indicated per patient assessments.

Primary contacts of community liaisons are: . The Department of Social Services . Mental Health Center .

Local and Surrounding Private Physicians . Pregnancy Medical Home . The Pregnancy Care Center .

Nash-Rocky Mount Schools . The Bassett Center . Nash UNC Hospital .

Wilson Medical Center Job Description: Social Worker II - CMHRP . ECU Health . State and Regional Consultants .

Prepaid Health Plans For the Care Management for High Risk Pregnancy Program to function efficiently it must be integrated with other programs within the agency, requiring contact with nurses, lab technologist, sanitarians, health educators, and management support. E. Supervision Received by Employee: Records are audited a minimum of quarterly for compliance with State and local policy by supervisor.

Records of clients receiving Medicaid are subject to Medicaid audit to see if components for reimbursement are being met. Written performance evaluations are completed annually per agency's policy. III.

Other Work Characteristics A. Work Environment and Conditions: Work environment may include the patient's home, exam room, or agency office. In the patient's home, the CMHRP CM is exposed to potentially hazardous conditions when patients may be violent, mentally ill or impaired with drugs or alcohol.

CMHRP Care Managers are encouraged to make visits in teams of two when the home is considered potentially dangerous. During extended work hours, visits are made in pairs or with the assistance of law enforcement personnel. Adverse weather conditions may constitute the rescheduling of visits until a time when travel is safer.

B. Machines, Tools, Instruments, Equipment and Materials Used: . Care Management for High Risk Pregnancy Standardized Plan .

Virtual Health Computer Software System . NCIR . Computer/EMR/Scanner .

Mental Health/Developmental Screening Tools . Copier . Computer/EMR .

Educational Materials . Fax Machine . Scales .

Automobile . 2-Way Radio . Office Phone and Personal Cell Phone C.

Accuracy Required in Work: Accuracy is required to ensure that all State, and local program guidelines are met. Accuracy is required in systematically identifying needs through efficient interviewing and assessing client strengths and weaknesses. Accuracy is necessary in counseling clients at all times and especially in crisis situations.

Accurate and appropriate referrals are also mandatory in this position. Accuracy is required for recording in client's records. D.

Physical Effort: This employee must be prepared to physically provide direct patient care each day whether this be through providing a clinical skill, home visit, phone call, or attending a continuing education session. This employee must be able to provide direct patient services each day. Must be able to drive to local hospitals, client's homes, doctor's offices, etc.

E. Visual Attention: Must be able to drive a car. Daily documentation is required in the patient's medical record and on reports.

Observation of the patient and family is also necessary. Job Description: Social Worker II - CMHRP F. Mental Concentration: Concentration and alertness is required daily when communicating with patients and other professionals.

Maintaining patient's records and required reports also demands mental concentration. G. Safety for Others: CMHRP CM must be knowledgeable of current Policies, Procedures, and Standing Orders.

Follow infection control guidelines and be adequately immunized according to agency's employee health policy. Confidentially is a main safeguard that must be available to the patient. It is the social workers responsibility to provide a confidential atmosphere for working with patients.

Knowledges, Skills and Abilities Considerable knowledge of social work principles, techniques, and practices and their application to individual casework, group work, and community problems. Knowledge of the psychosocial, socioeconomic and behavioral problems and their treatment. Knowledge of governmental and private organizations and community resources.

Knowledge of laws, regulations, and policies which govern the program. General knowledge of medical terminology, disease processes and their treatment is required in certain programs or settings. Skill in establishing rapport with a client and applying techniques of assessing psychosocial, behavioral, and psychological aspects of client's problem.

Ability to help patients obtain assistance in many areas, including financial and housing needs; to adjust to sometimes extreme psycho/social pressures is essential. Must have proven skills in counseling. Must be able to communicate effectively and maintain good rapport with patients and their families.

Must demonstrate good judgement and reasoning abilities. Must handle all contacts with the public in a courteous, professional and prompt manner. Coordinate services with community agencies, medical centers, physicians, etc.

Desirable Education and Experience Minimum Training and Experiment Requirements: i. Social workers with a Bachelor of Social Work (BSW, BA in SW, or BS in SW) or Master of Social Work (MSW, MA in SW, or MS in SW) from a Council on Social Work Education (CSWE) accredited social work degree program. ii.

ii. Registered nurses iii. iii.

Bachelor's degree in a human service field with 5 or more years of care management/case management experience working with the specific population of low-income, pregnant individuals and/or children ages 0 to 5 years iv. iv. Bachelor's degree in a human service field with 3 or more years of care management/case management experience working with the specific population (low income, pregnant individuals and/or children ages 0 to 5 years and has certification as a Case Manager (CCM preferred) C.

License or Certification Required by Statute or Regulation: Valid North Carolina Driver's License.