ToC Social Worker *Baltimore

Description *This position will be doing home and facility visits in Baltimore 4-5 days/week*

Summary/Position Objectives

The Social Worker on the Transition of Care (TOC) team supports high-risk members at a critical point in their care by addressing complex social barriers and helping guide a successful return to the community following hospitalization. Working collaboratively with facility case managers, nurses, and an interdisciplinary care team, the TOC Social Worker provides short-term, high-impact interventions focused on stabilization, safety, and connection to community resources. You will meet members where they are—often face-to-face—and use clinical judgment, motivational interviewing, and problem-solving skills to support recovery, independence, and continuity of care. About Maryland Care Management, Inc. (MCMI) Maryland Care Management, Inc. (MCMI) manages Maryland Physician Care's (MPC) statewide provider network of hospitals and physicians. Maryland Physicians Care has been providing services to the HealthChoice Medicaid populations since 1996, and we are proud of our footprint in the community. With over 230,000 members, MPC consistently has been one of MD's largest Medicaid-managed care organizations.

• Why join us?
• MCMI recognizes the importance of flexibility and offers multiple work arrangements.
• Along with competitive pay, we offer excellent benefits (medical, dental, and vision plans, 100% employer Term Life Insurance, Short and Long-Term Disability, 401k Employer Match up to 4%) as well as 20 days of PTO, and tuition assistance/professional development plans.
• Your future colleagues at MCMI are welcoming, friendly, and eager to help each other succeed.
• We are committed to Diversity, Equity, and Inclusion, providing organizational-wide social opportunities, and constantly improving our ongoing efforts to positively impact our members' lives.

What You'll Do

• Evaluate members based on their needs and limitations based on referrals. Will work directly with the Hospital/SNF case management staff to assist with the coordination of care and discharge plans for identified members. Will collaborate directly with members and their families to build a rapport to assist with discharge needs as appropriate. Address member concerns and goals while maintaining constant communication with the member. Utilizes clinical judgement to assess members, prioritizing emerging issues to maintain a member-centric approach. Collaborates with interdisciplinary care team at the facilities to support member health goals via conference calls, rounds, and consultation, which may include face-to-face meetings. Complete assessments to better understand the Social Determinants of health and social issues impacting member care goals. Utilizes problem-solving skills to research and identify community resources and coordinate a referral mechanism. Plans specific objectives, goals, and actions designed to meet the members’ needs as identified in the assessment process that are action-oriented, time-specific, and cost-effective. Implements specific activities and/or interventions that lead to accomplishing the goals outlined in the plan of care. Develop trusting relationships with members by providing support and advocacy to help achieve health goals. Monitors care management activities, services, and members’ responses to interventions, to determine the effectiveness of the plan of care and the utilization of services. Evaluate the effectiveness of the plan of care in reaching desired outcomes and goals; makes modifications or changes in the plan of care as needed. Make connections with members through visits to the hospital, home, and community via face-to-face, telephonic and/or video conferencing. Participates in outreach activities to promote knowledge of the program and its services and to coordinate program activities with outside community agencies and health care providers. Work with the MPC Case Management Team for an appropriate transition of care.