Part-Time, M-F, Occasional Weekend and evening Work

Polk County is seeking a unique individual who has a passion for working with at-risk children.  We have an innovative model of service delivery that promotes a comprehensive team approach to providing quality service to our community.  In addition to services for adults and children the Polk County Consolidated Human Services Agency includes program divisions for Senior Services, Social Services, Public Health, Public Transportation, and Veteran Services. 

General Statement of Duties
It is the goal of Polk County HHSA – Public Health Division to promote and protect the health of the citizens of Polk County. The Division provides resources, support, and advocacy to pregnant and parenting families. The Division educates, counsels, empowers and links Polk County residents with services to promote health and well-being.

The incumbent for this position functions as a Family Care Manager (FCM), providing services under the Case Management High-Risk Pregnancies (CMHRP) program. This position utilizes a care management approach to provide care management services in accordance with program guidelines, including condition-specific pathways, utilizing those interventions that are most effective in engaging patients and meeting their needs. This includes face-to-face encounters (practice visits, home visits, hospital visits, community encounters), telephone outreach, professional encounters and /or other interventions needed to achieve care plan goals.  This position also aids in operating the Division’s Healthy Opportunities Program (HOP).

Duties and Responsibilities

• Major Activities:
  • The Family Care Manager will build a caseload of clients by following up with referrals from the Agency, Hospitals, and other medical providers serving Polk County residents.
  • Major activities of this position include assessment, counseling, group activities, outreach, case management, recruitment, service planning, coordination and referral, follow-up and monitoring, and education.
  • Eighty-five percent of the Care Manager’s time involves in-depth counseling which includes assessment, service planning, diagnosis and treatment as it relates to the client’s medical and emotional needs, behavioral and environmental problems. Ten percent of time is spent in outreach and recruitment, community liaison, education, coordination and referral, follow-up and monitoring. The Care Manager will use a self-directed approach to teach the client about health as it relates to prenatal care, the birthing process, family planning, parenting skills, and the special needs of the child and family. Five percent of the worker’s time is spent in consultation with fellow outreach team members and other professionals in the agency and community.
• Initial assessments:
  • Aids in determining the client/family service needs, which might include psychosocial, nutritional, medical, educational, and financial factors. The assessment, in conjunction with home visits, helps the worker identify services needed to help the client improve the holistic family situation. The Care Manager will analyze and develop a plan of action, which may include a creating priority goals and assigning conditions related to diagnosis and treatment plan, to be implemented with the client. Range of services may include assisting the family with housing, transportation, home management, parenting, day care, employment, counseling and education as appropriate. Based on the assessment, the Family Care Manager will assign a service intensity level which will stratify the level of services to be provided to the client.
• Follow-up and Monitoring:
  • Required to ensure that the care plan has a positive impact on the client. Close monitoring may lead to changes in the initial plan, as the Care Manager helps the client adjust to changes in the environment, family and medical situation. The Care Manager will ensure that the client has appropriate services in place.
  • Documentation of follow up and monitoring occurs through the Case Management Information System (CMIS), an electronic medical record, available through secure internet access.
  • Implementation of service plan is facilitated through intensive counseling sessions aimed at identifying and meeting client needs, modifying behavior, building confidence and self-esteem, developing better coping and problem-solving skills, and assisting the client to develop a support system. The Care Manager must be adept at crisis intervention skills in order to deal with multiple family and personal problems, which often develop into crisis situations within this target population. Continued efforts are made to prevent the development of protective service cases and high-risk medical problems, which could lead to low birth weight and death. Constant reassessments and evaluations are done to determine the effectiveness of the service plan.
• Outreach and Recruitment:
  • This employee encourages families to participate in care coordination services to secure the best possible health and development outcomes. The Care Manager evaluates Medicaid status, explains services available to the client.
  • The Care Manager develops a strong referral network and increases community awareness of programs. Strategies will be developed for community outreach to market the programs to the target population, health care providers and the community at large. This will involve giving presentations to community groups regarding the benefits of programs. The Care Manager encourages referrals from local providers, community groups, and in-house staff.
• Education and Counseling:
  • This employee educates and informs the client of needed services and strategies for accessing necessary resources, and educates client in preparation for childbirth and parenting. If offered, the Care Manager assists with coordination of parenting and childbirth classes within the Agency. Understanding and evaluating group dynamics are crucial to this phase of the job, as the Care Manager must facilitate group learning through planning and appropriate intervention in group interaction. The Care Manager reinforces nutritional counseling from WIC or agency nutritionist and assists the family in plans for continuing health care and in anticipation of future health needs.
• Coordination and Referral Skills:
  • Coordination and referral are required in order to assist the client in utilizing appropriate services and to ensure continuity of care. Consultation with appropriate persons/agencies will be routinely scheduled to implement and monitor the service plan. The Care Manager serves as a liaison between other programs such as Social and Economic Services, WIC, Mental Health, the Division of Medical Assistance, Family Planning Clinics, Well-Child Care Clinics, local hospital, and local private medical providers. The Care Manager consults and cooperates with the judicial system by serving as an expert witness regarding neglect and abuse cases. The Care Manager must possess good public relations skills, as s/he will be in daily contact with multiple community agencies.
  • Accurate and completed documentation is required in order to assure program accountability and quality assurance auditing.
  • Continuous Quality Improvement (CQI) Care Manager is responsible for participating on a Continuous Quality Improvement to assist in ongoing internal monitoring of care management programs.
• This employee performs other duties as assigned by the Supervisor.

Knowledges, Skills, & Abilities:
This position requires considerable knowledge of and skills in the application of social work theories, principles, practice, and techniques employed in the field of public health; considerable knowledge of available community resources; ability to plan and coordinate, to deal tactfully with others and to exercise good judgment in appraising situations and making decisions; the ability to be flexible and to work as a team player; good verbal and written communication skills; and excellent listening skills and considerable knowledge of maternity and child development issues.
Required Minimum Training: Registered nurses; or Social workers with a bachelor’s degree in social work (BSW, BA in SW, or BS in SW) or master’s degree in social work (MSW, MA in SW, or MS in SW) from a Council on Social Work Education accredited social work degree program. Care Managers for High- Risk Pregnancy hired prior to September 1, 2011 without a bachelor’s or master’s degree in social work may retain their existing position; however, this grandfathered status does not transfer to any other position.
Additional Training/Experience: Experience in techniques of community organization, casework, and group work are needed in this position to enable the worker to interact with the outreach and perinatal team and network with other community agencies, physicians and hospitals.
Basic Computer skills: Word, Excel, e-mail, and online systems.
All employees may be called upon to perform work during emergency or disaster situations including but not limited to staffing shelters overnight.   This service, if required, will take precedence over duties described in this position description.
Possession of a valid North Carolina driver’s license (Class C) with limited restrictions and demonstrated a good driving record.
Applicants must pass criminal justice background investigation and drug screen.

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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