Bilingual Medical Social Worker MSW

Suvida Healthcare•Tucson, AZ

15d

About The Position

The Senior Guia systematically intervenes to provide clinical social work and complex case management to patients and their families who have complex psychosocial needs, require assistance with eligibility determination for social programs and funding sources, and qualify for community assistance from a variety of special funds and agencies. This position assesses the patient’s plan of care and develops, implements, monitors, and documents the utilization of resources internally and externally and progress of the patient through the continuum of care. The intensity of care coordination provided is situational and appropriate based on patient need and payer requirements. This role participates in an interdisciplinary team (including Physicians, Case Managers, Staff Nurses and other members of the care team) to provide services for high risk patients and ensure that psychosocial needs are attended to and treated as required across the continuum of care.

Requirements

Acute inpatient hospital social work experience preferred
Experience managing the needs of Senior/Geriatric populations
Experience assessing and addressing the social determinant of health
Working knowledge of ICD-10 and Z codes
Proficiency with EMRs, computers, mobile devices, medical devices, and Microsoft Office Suite
Excellent therapeutic communication and negotiation skills in interactions with patients, families, physicians, and health care team colleagues
Exposure and/or experience in pre-acute and post-acute care
Expertise connecting patients and ensuring closed loop referral with community resources and governmental agencies that address complex social needs
Ability to work independently, as well as, to develop collaborative relations with physicians, families, patients, interdisciplinary team members, and community agencies
Requires a Licensed Master Social Worker (LMSW) or equivalent
3-5 years of experience AND CHW certification plus 6- 8 years social work experience.
Must have knowledge of government/community resources as well as Medicare, Medicaid, long-term care, or any other applicable resources/services
Must have knowledge for transacting LIS, PAP, and SNAP applications and other foundation applications
Must demonstrate critical thinking skills, problem-solving abilities, effective communication skills, relationship building skills, and time management skill

Nice To Haves

Graduate of an accredited Master of Social Work program (MSW) preferred

Responsibilities

Provides comprehensive care coordination to an assigned patient caseload
Works collaboratively with patients, family, caregivers, healthcare providers, and external partners to meet complex medical patient needs
As part of a multidisciplinary team, develops and carries out a treatment plan by the use of a clinical social work diagnosis, assessment and treatment interventions
Intervenes with patients and families regarding emotional, social, and financial consequences of illness and/or disability
Assesses, mobilizes and provides follow up on family/community resources to meet social care needs
Provides intervention in cases involving elder abuse/neglect, domestic violence, guardianship (temporary/permanent), mental health placement, and sexual assault
Initiates and assists patients with advance directives
Collaborates with patients/caregivers to include supportive care, end-of-life decisions, community resources/programs, goal setting, and long-term planning needs
Formulates care plan of intervention acceptable to the patient, family, and health care team
Receives referrals for complex patient problem resolution from case managers or clinical care team members
Works in collaboration with the clinical and case management team on transitions of care planning and referrals to post acute providers
Promotes a collaborative process and communication between all health care team members, internal multidisciplinary teams, inclusive patients/clients, families, and significant others to ensure the process of integrated care services are targeted, appropriate, and beneficial
Advocates utilizing knowledge of applicable laws, regulations, government, and insurance benefits as well as practice guidelines and standards of practice
Advocates for patient and family empowerment and independence to make autonomous health care decisions and access needed services within the health care system
Provides follow up and assistance to patients in a variety of settings: in-home, in-clinic, and in the ancillary setting- hospitals, group homes, skilled nursing facilities, etc.
Documents all interventions in the patient medical record both timely and accurately including all elements of clinic visits, in home, telephonic engagement, or texting
Maintains knowledge of Medicare, Medicaid, and other program benefits to assist patients with resource allocation and choices
Has freedom to determine how to best accomplish functions within established procedures
Provides consultation to low risk guias on patients with significant or intensive community resources needs
Participates in the development and maintenance of case management metrics
Provides professional education to staff and community
Facilitates Suvida sponsored support groups
Other duties as assigned by Guia Manager