Community Social Worker

ChenMed•Philadelphia, PA

2d•$54,358 - $77,655•Onsite

About The Position

The Community Social Worker (Social Complex Care Manager, SW) works closely with the PCP, Medical Specialists and other members of the Complex Care team such as Post Hospital Care Coordinators, Post Hospital Care Manager, Hospital Care Managers, and Intensive Community Case Managers. This role is on-site Monday through Friday and supports multiple ChenMed offices in Philadelphia. The incumbent in this role is responsible for providing psychosocial assessment, social casework and linkage to community resources for complex patients who have chronic, life threatening or altering diseases and disorders and may be at high risk for hospitalization. The incumbent in this profile advocates for services and resources for the underprivileged and victims of abuse, neglect, or other difficult personal situations to help them maintain an optimum level of health and prevent hospital arrivals. Community Social Workers will adhere to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance, and policies and procedures as defined by industry standards and the enterprise. The success of this role is determined by the impact social needs management has on patients with complex social needs on preventing unnecessary hospital arrivals.

Requirements

BS degree in Social Work required
A minimum of 2 years’ work experience in social work, case management, and/or discharge planning experience required
State Licensure is required
If applicable, incumbent must be compliant with the mandatory laws of state licensure at the Master’s level.

Nice To Haves

Master’s Degree of Social Work (MSW) preferred
A minimum of 2 years’ experience in a primary care setting preferred

Responsibilities

Conducts timely and appropriate assessment and needs identification, prioritizing patients on the Intensive Community Care (ICC) program, PCP’s High Priority Patients (HPP) and Top 40 patient lists. Assesses the patients for psychosocial, financial, family issues, palliative care/end of life issues, home safety, etc. that negatively impact their health outcomes and at risk for hospitalization.
Communicates with PCPs and interdisciplinary Care Team in order to support and advise concerning social needs and resources available in community resource database.
Conducts appropriate assessment of needs and financial benefit eligibility.
Assesses patients for Medicaid criteria and assists with application process as needed.
Assists patients to obtain community resources/services as appropriate, e.g. meals, medications, housing, daycare, HHA and other SDoH needs as identified.
Serves as care coordinator linking patients with internal and external resources, prioritizing complex patients whose needs can lead to unnecessary hospital arrivals.
Educates center staff, other members of the care team, patients and caregivers on how to access community resources as identified by the patients SDoH Wellness Screening.
Works with patient, family, and interdisciplinary care team to facilitate applications for higher level of care.
Maintains an accurate repository of social wellness tools and resources for the care team’s awareness and utilization with patients in need.
Maintains communication with interdisciplinary team members by attending appropriate meetings (i.e. weekly Super Huddles and Hospital and Community Care Team (HCT) meeting.)
Provides consultation in an integrated health care environment regarding social determinants of health and community resources.
Maintains timely, accurate, thorough and appropriate documentation/reports per company policies and procedures. Initial psychosocial assessments will be completed within 48 hours. All follow- up visits, phone calls and collaborative contacts will be documented within 24 hours. Assures documentation meets billing guidelines.
Works closely with the Complex Care Team to secure the appropriate level of care post hospital/SNF discharge. Further interventions may be conducted in the center, by phone call or patient’s home.
Performs other duties as assigned and modified at manager’s discretion.