Medical Social Worker – LCSW Preferred! Tampa Bay/Pinellas area

ChenMed•Saint Petersburg, FL

7d•Onsite

About The Position

We are a unique and rapidly expanding healthcare organization dedicated to transforming lives for both our patients and our team members. We are seeking innovative, entrepreneurial-minded individuals with a strong work ethic and ambition to join our team. The Community Social Worker (CSW) is an integral part of the care treatment team, collaborating with PCPs, Medical Specialists, and Care Nurses. This role is responsible for providing psychosocial assessment, social casework, and linkage to community resources for patients with chronic, life-threatening, or altering diseases and disorders. The CSW 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. Adherence to strict departmental goals, standards of performance, regulatory compliance, quality patient care, and policies and procedures is expected.

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
Keen business acuity and acumen
Full knowledge and understanding of general Social Worker functions, practices, processes, procedures, and techniques
Knowledge of social services documentation procedures and standards
Knowledge of community health services and social services support agencies and networks
Knowledge of normative changes (e.g., sensory, cognitive, psychosocial) associated with aging for high-risk patients
Knowledge of advance care planning and palliative care, and related skill in addressing advance care planning
Ethical practice behavior consistent with ChenMed policies and professional standards
Skill in psychosocial interventions with challenged caregivers/family systems of high-risk patients
Appropriate utilization of community-based resources
Teamwork skills in care coordination with patients, family systems, staff, and external providers
Ability to work autonomously is required
Ability to monitor, assess, and record patients’ progress and adjust accordingly
Ability to communicate technical information to non-technical personnel, and with patients and/or their family systems
Strong interpersonal, communication, and critical thinking skills and the ability to work effectively with a wide range of constituencies in a diverse community
Demonstrated ability to provide care effectively and sensitively to people from different cultural groups
Ability to create a collaborative relationship to maximize the patient’s/family’s ability to make informed decisions
Proficiency in written communication: documentation is clear, concise, accurate, provides meaningful communication and is consistent with company policy and regulatory requirements
Proficiency in technology, including the utilization of Electronic Medical Record platforms for care coordination
Proficient in Microsoft Office Suite products including Word, Excel, PowerPoint and Outlook, plus a variety of other word-processing, spreadsheet, database, e-mail and presentation software
Ability and willingness to travel locally, regionally and nationwide up to 10% of the time
Spoken and written fluency in English
This job requires use and exercise of independent judgment

Nice To Haves

LCSW Preferred
Master’s Degree of Social Work (MSW) preferred
A minimum of 2 years’ experience in a primary care setting preferred
State Licensure at a Master’s Level is preferred but may be required (dependent on state)
Spanish Bilingual Preferred

Responsibilities

Conduct 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.
Assess patients for psychosocial, financial, family issues, palliative care/end of life issues, home safety, etc., that negatively impact their health outcomes and put them at risk for hospitalization.
Communicate with PCPs and the interdisciplinary Care Team to support and advise concerning social needs and available community resources.
Conduct appropriate assessment of needs and financial benefit eligibility.
Assess patients for Medicaid criteria and assist with the application process as needed.
Assist patients to obtain community resources/services as appropriate, e.g., meals, medications, housing, daycare, HHA, and other Social Determinants of Health (SDoH) needs.
Serve as a care coordinator, linking patients with internal and external resources, prioritizing complex patients whose needs could lead to unnecessary hospitalizations.
Educate center staff, other care team members, patients, and caregivers on accessing community resources identified by the patient's SDoH Wellness Screening.
Work with patients, families, and the interdisciplinary care team to facilitate applications for higher levels of care.
Maintain an accurate repository of social wellness tools and resources for the care team's awareness and utilization.
Maintain communication with interdisciplinary team members by attending appropriate meetings (e.g., weekly Super Huddles and Hospital and Community Care Team (HCT) meetings).
Provide consultation in an integrated health care environment regarding social determinants of health and community resources.
Maintain timely, accurate, thorough, and appropriate documentation/reports per company policies and procedures. Initial psychosocial assessments must be completed within 48 hours. All follow-up visits, phone calls, and collaborative contacts must be documented within 24 hours. Ensure documentation meets billing guidelines.
Work closely with the Complex Care Team to secure the appropriate level of care post hospital/SNF discharge. Interventions may occur in the center, by phone, or at the patient's home.
Perform other duties as assigned and modified at manager’s discretion.