Ambulatory Care Mgmt Social Worker

TriHealth•Cincinnati, OH

About The Position

Collaborates with primary care providers (PCPs) and multidisciplinary teams to support patient populations with chronic illness and multiple comorbidities. The care manager social worker follows established care management standards incorporating evidence-based protocols, cost-effective approaches, and patient-focused interventions. Applies social work methods to assessment, education, collaboration, and coordination of healthcare and community resources to help patients develop self-management skills, achieve optimal functional health, and improve quality of life. Provides support to patients and families, care teams, and healthcare systems through telephonic, in-person, and/or home visits. Uses knowledge of community and government agencies and support groups to connect patients with appropriate TriHealth and community referrals. Provides support services to the PHO and its value-based contract members, including care coordination, home health visits, and counseling.

Requirements

Bachelor’s degree in Social Work, Addictions, or Counseling.
3–4 years of experience.
Required Licensed Clinical Social Worker (LCSW) license.

Responsibilities

Assess, plan, implement, monitor, and evaluate individualized, patient-centered care to optimize health through support systems, community resources, specialist coordination, and patient education.
Develop plans to address patients’ psychosocial, socioeconomic, and behavioral issues.
Communicate and collaborate with PCPs and clinical staff about psychosocial barriers to health maintenance and coordinate referrals to indicated services.
Collaborate with clinical and medical personnel across inpatient and outpatient service lines to support continuity across care settings and transitions.
Provide end-of-life discussions and initiate referrals for palliative care and hospice.
Conduct psychosocial assessments, establish goals, assess progress, support evidence-based protocols and care plans, address barriers, and complete required documentation.
Provide targeted interventions for high-risk patients to improve health outcomes and coordinate care across settings.
Help patients and families understand healthcare options and promote self-management and patient/family capacity for self-care and independence.
Use registries, reports, and tools to identify target populations and patients.
Plan and manage a panel of patients with chronic or complex diseases; tailor interventions to diagnoses, age, abilities, and resources; and establish patient-directed learning and disease self-management plans.
Participate in quality improvement activities, including data collection, chart review, interdisciplinary collaboration, patient-data analysis, and interprofessional staff meetings.