Social Worker II - CMHRP

Posting number: 2026-00051

Department: Health Department

Job classification: SOCIAL WORKER II

Posting type: External & Internal

Categories: Public Health

Summary

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.

Examples of duties

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 t