Social Work Coordinator

Denver Health and Hospital Authority•Denver, CO

4d•Onsite

About The Position

Under general supervision, the Health Plan Denver Health Pediatrics at Denver Public Schools School-Based Health Center (SBHC) Social Work Care Coordinator (SWCC) is responsible for facilitating and coordinating the care delivered to an assigned group of patients members using multidisciplinary and member/family collaboration to ensure quality and cost effective outcomes are delivered within appropriate care coordination parameters. Coordination involves assessment of care needs, planning, support, and evaluation of member care and related outcomes. Activities to be performed are screening and assessment of medical, behavioral health and social determinants needs and gaps in care, collaboration with the Member to develop a care plan with SMART goals, scheduled outreach to support member in achieving their goals and supporting the Members patients' self-efficacy to navigate systems. SWCC communicates closely with the Member's care team inclusive of: the Member, designated health representatives, primary care provider, behavioral health providers and other care coordinators involved with the Member's Patient's care. Encounters occur face to face, telephonically, and electronically with members patients in clinic and in other community-based settings. Position is an active contributor in the development of systems (e.g., workflows, clinical pathways, assessments) to improve the care of assigned member patient populations. Helps ensure compliance with state, federal and third party payor requirements.

Requirements

High School Diploma or GED
One year of direct member care experience in acute, ambulatory care or community based care
Bilingual in English/Spanish, preferred.
Knowledge of emotional and social factors that impact patient’s health.
Excellent interpersonal skills.
Skilled in identifying problems/opportunities to improve care.
Ability to help the patient and family to understand, accept, and follow medical recommendations.
Ability to utilize resources, such as family or community agencies, to assist the patient to resume life in the community.
Ability to collect key information from the patient, family, and the community, as part of the social work assessment.
Ability to communicate to the appropriate staff, information about the patient.’s discharge plan.
Experience with windows-based computer programs and ability to use computer for data analysis and data display, required.
Experience with Medical Management platforms used to document care coordination services, preferred.

Nice To Haves

Bilingual in English/Spanish
Experience with Medical Management platforms used to document care coordination services

Responsibilities

Utilizes Care Coordination Processes: Systematically collects focused data relating health needs and concerns of member/patient, group, or population. Establishes and maintains member/patient-centered relationships. Analyzes assessment data to determine opportunities for health promotion, health maintenance or health related problem needs and statements. Identifies and executes evidence-based interventions to support the Member/patient in achieving their health goals. Identifies and works towards expected outcomes in a plan of care individualized for a specific member/patient, group or population. In collaboration with the patient/Member, develops a care plan that identifies strategies and alternatives to attain expected outcomes. Utilizes competent, evidence based, telephone encounters and electronic communications according to regulatory requirements and standards, as well organizational policies and procedures. Conducts systematic evaluation of outcomes of care coordination in relation to structures and processes determined by grant. Documents in readable, understandable language according to professional, regulatory, and agency standards. Documents and disseminates results of care to member/patient, caregivers, and others involved in the care or situation, as appropriate, in accordance with contractual requirements, state and federal laws, regulatory requirements, and Denver Health policy.
Provide Care Coordination Services: Coordinates the delivery of care within the clinic setting, throughout the organization, and across health care settings. Provides relevant information across the care system, within Denver Health and with other healthcare systems and payers when member care is transferred between and among different specialties and/or within one or more organizations. Provides information to the health care team including the member/patient, family, and caregiver regarding available resources and benefits for health care services that ensures member choice and safe, timely transition. Serves as point of contact within and among healthcare services and organizations. Coordinates community resources. Assures designation of primary responsibility among team members for each aspect of care plan, avoiding duplication and fragmentation. Facilitates continuity of care using the multidisciplinary collaboration, and coordination of all appropriate healthcare services and community resources across the care continuum. Orients member/caregiver/patient to health care delivery system, services, access, and resources.
Health Teaching and Promotion: Identifies barriers to goals and strategies to address. Provides personalized education for optimal wellness. Encourages preventative care such as immunizations and cancer screening. Promotes appropriate utilization of resources. Assists and educates caregiver when member is unable to participate. Incorporates therapeutic communication, health literacy, cultural, and linguistic needs and preference into education and goals. Supports members/patients and caregivers in developing skills for self-efficacy to promote, maintain, or restore health such as healthy lifestyle tips, risk-reducing behaviors, age and developmental needs, daily living activities, and preventative care.
Care Coordination: Responsible for a defined caseload of Members enrolled in the DHMP Medicare Choice Dually-eligible Special Needs Program (DSNP) patients who are identified as having a medium or low risk acuity level using data from a variety of sources, including the Member/patient, their caregivers, providers, administrative claims data, pharmacy data and other inputs. The DSNP Model of Care is a well-defined model requiring a comprehensive health risk assessment (HRA), individualized care plan (ICP) and integrated care team (ICT) review of the ICP. This routine is completed at least annually and more frequently when the Member experiences a change in condition, as evidenced by hospitalization, movement to a residential place of care or other event. Obtains Member/patient consent to participate in the program as well as to share clinical information with the Member’s/Patient’s care team. Works collaboratively with the patient/Member to set SMART (specific, measurable, attainable, realistic and time-limited) goals and to graduate the Member to lower-intensity care programs and self-care within reasonable timeframes. Works under the supervision and advice of the Supervisor who can provide insight into medical conditions, treatments, medications and answer medically-related questions as needed.

Benefits

Generous paid time off
Fully paid parental leave
Exceptional retirement contributions
Comprehensive health coverage
Nationally recognized well-being programs
Tuition assistance
Career advancement pathways
Professional development
Loan forgiveness eligibility
Employer contributions
Paid time off starting at 28 days per year, inclusive of vacation, personal/sick, and 7 Holidays
100% paid parental leave up to 6 weeks
Immediate eligibility for retirement plans with employer contribution up to 9.5%
Generous medical, dental, vision plans in addition to employer paid disability and life insurance.
Comprehensive well-being programs including on-site employee fitness center located on Denver Health main campus and nationally recognized RESTORE Center
Free RTD EcoPass (public transportation)
Childcare discount programs & exclusive perks on large brands, travel, and more
Tuition reimbursement & assistance
Education, coaching, and professional development opportunities through the Workforce Development Center (WFDC) that support internal career growth and advancement pathways
Professional clinical advancement program & shared governance
Public Service Loan Forgiveness (PSLF) eligible employer
Free student loan coaching and assistance navigating the PSLF program
National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer