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Social Work Care Manager -- House Calls

North Shore-LIJ Health System

Nassau, NY
Job Code:
  • Medical/Surgical
  • Hospice/Palliative Care
  • Long Term Care
  • Psychiatric/Behavioral Health
  • IV Therapy
  • Utilization Review
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Job Details

Job Title: Social Work Care Manager -- House Calls
Job Number: 00145Y

Works with team members, patients, families and caregivers in performing care coordination efforts to provide comprehensive care management to homebound chronically ill patients. Able to access knowledge and experience in a variety of fields of human service to address the bio-psycho-social and cultural needs of the patient and family. Coordinates psychosocial assessments, advance care planning, behavioral health support, bereavement support, crisis intervention, and transitional planning. Promotes education, self-management support, and timely healthcare delivery to achieve optimal quality of life for patients and families.

Responsibilities Include:
  • Conducts initial psychosocial assessment of patients by interviewing patient, family, and significant others to determine support structure, cultural needs, emotional and psychological needs.
  • Formulates and implements a psychosocial care plan that addresses patient identified needs by assessing resources and care goals.
  • Collaborates with healthcare team involved in patient’s care to enhance care plan and integration of services. Contributes to the understanding of social and emotional elements of patient’s life related to their diagnoses and treatment.
  • Works in interdisciplinary team to assist with complicated and high risk cases to foster positive outcomes.
  • Promotes patient self-management and empowers patient/families to achieve maximum levels of wellness and independence.
  • Identifies and effectively utilizes community resources to help meet the needs of patient/families.
  • Provides transitional care services to patients:
    • Visit patient in hospital and/or skilled nursing facility.
    • Works with hospital and/or facility care teams to expedite patient's safe and timely discharge.
    • Visit patient post-discharge in home setting to foster transition into homecare services.
  • Provides patient with clear instructions and education utilizing appropriate guidelines.
  • Participates in education and in-service programs.
  • Completes documentation in accordance with policies and procedures of the organization, State and Federal regulations.
  • Performs related duties, as required.



* ADA Essential Functions

  • Master Degree of Social Work, required.
  • Current New York State license in good standing  to practice as LMSW or LCSW, required.
  • Care Manager Certification, preferred.
  • Current, valid New York State Driver’s license, required.
  • Minimum of three (3) years experience in two (2) or more of the following: case/care management, discharge planning, advocacy, outreach, hospice, supportive counseling, required.
  • Knowledge of third party payer requirements, required.
  • Working knowledge of Microsoft applications (Excel, Access, Outlook), required.
  • Demonstrates progressive proficiency with the utilization of available technology.
  • Demonstrates customer service, leadership, communication and problem solving skills required. Sensitive to cultural diversity and low literacy issues in care provision.
  • Rotating Weekends and Holidays as required
  • Must be able to travel  to patients homes in Queens and Nassau as needed

Job Social Workers

Primary Location Nassau County-New Hyde Park-1983 Marcus Ave

Schedule Full Time

Shift Day Job

Shift Detail 

North Shore-LIJ Health System is the nation's third largest non-profit, secular healthcare system, New York City's ninth largest employer, and the largest employer on Long Island.