1. A. Primary Purpose of Organizational Unit:

Provide Care Management services to Cumberland County residents meeting targeted risk criteria’s by promoting health and stressing prevention through screening, assessments, education, referral, follow-up, community outreach and collaborations with Primary Care Physicians and Providers to maintain healthcare cost, linkage to Primary Medical Providers with continuity care.

1. Primary Purpose of Position:

The Social Worker position works within the Nursing Division’s multidisciplinary Care Management for High-Risk Pregnancy (CMHRP) Program. In conjunction with Nurses this position provides Care Management services and education to all pregnant Medicaid recipients determined to be high-risk and qualify for services via positive identification on pregnancy risk screening tools and other referral sources, with the goal of improving birth outcomes, improved quality, and continuity of maternal and primary healthcare. Other social worker related support services include assisting individuals and families in such areas as counseling, parenting, developmental screening, and preventative health follow-up are provided.

1. Work Schedule

This position works a forty (40) hour work week. Normal work hours are Monday through Friday from 8:00 AM to 5:00 PM with a one-hour lunch break. Flexible scheduling is implemented if extra hours are accrued on any workday.

Employee is subject to be called upon anytime to help the agency respond to a public health emergency which may include,  but is not limited to, outbreak investigations, staffing mass dispensing or immunization clinics, providing disaster relief, or other incidents (man-made or natural and intentional or non-intentional) as they arise, or any public health response requested by the Health Director.

1. Change in Responsibilities or Organizational Relationship:

N/A

1. A. DESCRIPTION OF RESPONSIBILITIES AND DUTIES: Must include % of time spent on each item.

Order of importance     Sequential order

95%                

Provide community outreach services by making contact and a plan of care with high-risk pregnancy women for the purpose of care management or any other social work function as a representative of the agency such as home, interdepartmental and WIC visits, Pregnancy Medical Home office and or other community agency visits. Employees in these roles carry a caseload of patients and/or families and work in partnership with them to identify strengths and needs and develop a plan for health maintenance or improvement. Employees provide a combination of case management and social work assessment to help patients and families manage health care needs. They make referrals to medical facilities, social service agencies, etc. when needed and agreed on by the patient or family. Employees take a lead role in coordinating all plans and resources for these clients. Maintain records of client care by documenting visits and reporting observations on assessments. Daily and weekly work is usually self-planned and coordinated with the team. Agency goals and patient care goals are understood. Employees will frequently have to make short-range plans and changes to meet client and program needs. Attend monthly staff and team meetings. Work is reviewed periodically for adherence to established public health standards and programmatic guidelines by a Public Health Nursing Supervisor II and Public Health Nurse III/Program Coordinator through review of written reports and oral conferences.

5%      

Other duties as assigned include participating in program planning and quality assurance activities such as contributing observation, data related to patient or community trends or practices, ideas for improved program performance, record audits and other program reviews. Participate in continuing education activities by attending workshops and seminars and maintaining necessary certifications. Skill sets may be applied as needed in any public health area, clinic, or program.

This job description in no way implies that the duties listed here are the only ones the employee can be required to perform. The employee is expected to perform other tasks as directed by their manager or supervisor.

II. B. OTHER POSITION CHARACTERISTICS:

1. Accuracy Required in Work:

Accuracy is required in providing guidance and direction to client, patient and to the professional staff in the assessment, intervention, and coordination of care and follow-up of the well-being of the population being served. Work requires more independent judgement in applying the professional standards and guidelines.

2. Consequence of Error:

Employees work and decision making have a substantial direct impact on the client population served. This position may be the only health professional to encounter the clients in the field or home.

3. Instructions Provided to Employee:

Daily and weekly work is self-planned and coordinated utilizing the program’s standardized plan. Agency and patient care goals are understood. Other instructions are provided by the Public Health Nurse III but are directly supervised by the Public Health Nursing Supervisor II.

4. Guides, Regulations, Policies and References Used by Employee:

Guidelines include public health standards, programmatic protocols, agency work standards, multi-agency policies and procedures as well as federal, state and county mandates.

5. Supervision Received by Employee:

This position is directly supervised by a Public Health Nursing Supervisor II, with some oversight received from the Public Health Nurse III. It functions with a great deal of autonomy. 

6. Supervision Provided and Number of Employees Supervised:

This position provides no direct supervision. It may direct volunteers, students, or other personnel occasionally during special assignments.

7. Variety and Purpose of Personal Contacts:

Employees have contact with a patient population in an assigned area which might not be familiar with public health standards and programs. Communication with patients must demonstrate sensitivity to the person’s culture, economic challenges, and other vulnerabilities, and must also recognize each patient’s strengths and abilities.  Work requires that employees work in cooperation with the patient, patient’s family (particularly in homes, schools, and other community settings) Primary Care Providers and other clinic staff to assess the patient’s health status and needs and assist in providing the services needed in order to maintain or improve their health. Patient education and counseling are important components of this service delivery. Employees may refer clients and families to a variety of services to meet financial, psychological, emergency care, emotional or other needs. The employee must also be aware of health trends and practices that are pertinent to the population of patients served.

8. Physical Effort:

This position requires the ability to mobilize throughout the clinic and move to outside locations to attend meetings or report to alternate locations or disaster responses.

9. Work Environment and Conditions:

Employees will have periodic exposure to hazards in the field (driving, rural or inner-city settings, inclement weather, clients) and to a lesser degree in clinic settings. They might be exposed to bloodborne pathogens, infectious diseases, or angry or disruptive patients.

10. Machines, Tools, Instruments, Equipment, and Materials Used:

Involves use of office equipment such as computers, telephones, printer, fax machine, calculator, vehicle, and PPE.

11. Visual Attention, Mental Concentration, and Manipulative Skills:

Visual and mental concentration is needed 100% of the time since an inaccurate assessment could result in inappropriate referrals to a resource that was not needed, or the staff might miss a problem due to a lack of concentration or attention.  It is imperative as results are given that may have a serious developmental and/or life and death or other serious consequence for them and the population at large.

12. Safety for Others:

Must always be cognizant of safety for self, patients, and staff.  Must also adhere to OSHA guidelines for universal precautions.

13. Dynamics of Work:

Employee must be able to establish rapport with clients, family members, professionals, and community leaders. Be flexible, motivated, and able to motivate others. Often review and assess complex or potentially complex conditions, considering both the physical aspects of the issue and the impact of other factors such as patient or family strengths and resources, income, culture, and family dynamics in order to help families develop and implement a usable plan of care. Must represent the agency in a professional manner. Demonstrate a pleasant, friendly, helpful, courteous, and approachable demeanor with staff, clients, and other agencies. Must be able to work successfully in a group and teamwork setting.

III. A.  KNOWLEDGES, SKILLS, & ABILITIES:

• Considerable knowledge of and skill in social work and case management principles.
• Solid understanding of public health issues.
• Familiar with effective counseling and crisis intervention strategies for disadvantaged and diverse client populations.
• Ability to apply social work principles and must have a working knowledge of current social and economic problems relating to the social work field and public health, including health disparities.
• Familiar with available resources and organizations and the ability to coordinate these as needed.
• Ability to deal tactfully with others and to exercise good judgment in appraising situations and making decisions.
• Ability to work in and maintain partnership with patients and with other service providers to elicit needed information.
• Strong computer skills to accurately record assessments, interventions, care plans and other services rendered and to interpret and explain records, reports, and medical instructions to allow communication of patient record documentation and accessing of information.
• Some ability to plan, coordinate, and supervise the work of others.

 B.  1. Required Minimum Training (Must match State classification spec):

Bachelor’s degree in social work from an appropriately accredited institution; bachelor’s degree in a human services field from an appropriately accredited institution and one year of directly related experience; bachelor’s degree from an appropriately accredited institution and two years directly related experience; or an equivalent combination of education and experience.

2. Additional Requirements:

Per the Program Guide, Management of High-Risk Pregnancies and At-Risk Children, Local Health Department (LHDs) shall employ care managers meeting CMHRP/ CMARC competencies defined as having at least one of the following qualifications:

1. 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.
2. Registered nurses: degree in nursing and licensed to practice in NC
3. 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 0-5 years
4. 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 0-5 years) and has certification as a Case Manager (CCM preferred)

Note: Care managers  for at-risk children hired prior to Sept. 1, 2011, without a bachelor’s or master’s degree in social work may retain their existing position only. This grandfathered status does not transfer to any other position.

Due to the need for all Health Department personnel to respond to emergency care within and outside of our agency, the employee must successfully complete a cardiopulmonary resuscitation (CPR) course. CPR training must be renewed before the expiration of the certification or every two (2) years, whichever is less.

Employee must attend annual OSHA, Fire, Safety, and other agency trainings and must act responsibly to ensure the safety for self, clinical staff, and patients. This position adheres to the agency Safety, HIPAA and Medical Records Policies and Procedures. Mandatory attendance to approved required local and statewide programmatic trainings and conferences.

Required to possess and maintain a valid North Carolina driver’s license. Must use and maintain a personal vehicle to perform the duties associated with this job.

3. Equivalent Training and Experience:

 IV. License or Certification Required by Statute or Regulation:

1. Signatures indicate agreement with all information provided, including designation of essential functions.

Supervisor's Certification: I certify that ( a ) I am  the immediate Supervisor of this position, that ( b ) I have provided a complete and accurate description of responsibilities and duties and ( c ) I have verified (and reconciled as needed) its accuracy and completeness with the employee.

Signature:____________________________Title:____________________________Date:________

Employee's Certification: I certify that I have reviewed this position description, completed by the above-named immediate supervisor, is complete and accurate.

Signature:____________________________Title:____________________________Date:_______

Section or Division Manager's Certification: I certify that this position description, completed by the above-named immediate supervisor, is complete and accurate.

Signature:____________________________Title:____________________________Date:________

HR Director’s  Certification: I certify that this is an authorized, official position description of the subject position.

Signature:____________________________Title:____________________________Date:________

About NCAPHA

The North Carolina Alliance of Public Health Agencies, Inc. is a 501(c)3 nonprofit organization founded in 1995 by a group of local health directors who needed a way to pool resources to negotiate more advantageous terms in vendor contracts. Over time NCAPHA, or The Alliance, became the go-to resource for its members providing solutions to the challenges facing them. We are committed to offering service solutions to help local health departments reduce costs and increase efficiencies. Our members include all 86 local and district health departments in North Carolina. The North Carolina Public Health Collaboration refers to the North Carolina Alliance of Public Health Agencies (the Alliance) and its two sister organizations: the North Carolina Association of Local Health Directors (NCALHD) and the North Carolina Public Health Association (NCPHA). We work closely together, collaborating to advance public health in North Carolina.

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