Social Worker Care Coordinator - Population Health

Mercy Health BSMH • Amberley, OH

5d • Remote

About The Position

In the capacity of a Social Worker, provide clinical care management services to identified eligible patients, coordinating care to obtain desired health outcomes, improve self-care abilities, and decrease unnecessary cost of care. Work as a member of Interdisciplinary Team (IDT) along with the Ambulatory Care Manager (ACM) and Care Coordinator to ensure the assigned patient’s individual needs are identified and addressed in a timely manner. Perform standardized comprehensive needs assessment, identifying and addressing barriers to care and aligning patients with available benefits and resources. This is a remote position supporting OH, KY, and IL.

Requirements

• Bachelor’s Degree (required)
• Master’s Degree or Licensure as required by state of practice (required)
• 2-3 years acute care, home health or case management experience
• Excellent interpersonal communication and negotiation skills.
• Strong analytical, data management and computer skills.
• Demonstrate basic knowledge of healthcare and health education across the lifespan in a practice health setting.
• Ability to work with individuals, groups and families.
• Familiarity and knowledge of Community Resources.
• Flexibility to work non- traditional hours.
• Works well in a Team Setting.
• Personal computer skills.
• Highly organized and detail oriented.
• Accepts responsibility and follows through on projects and activities

Nice To Haves

• Bachelor’s or Master’s Degree in Social Work (preferred)
• Case Management certification, LSW or LCSW (preferred)
• Experience with database entry, EMR documentation, Power Point preferred and basic Excel skills.
• Demonstrated success in improving the health of a distinct population of patients in the ambulatory or community setting

Responsibilities

• Maintain a caseload of patients according to department policies.
• Identify, enroll and manage patients in program for Complex Case Management.
• Develop and implement care plans to maximize wellbeing with periodic review and update according to department protocols.
• Collaborate with ACM, PCPs, Specialists, and Hospitalists to effectively implement a patient-centered care plan.
• Perform situational and family assessment of social determinants of care and develop goals as part of the comprehensive care plan.
• Perform patient outreach according to established protocols and document in electronic medical record.
• Identify, execute, and track needed referrals to care and community resources.
• Provide resource management to improve care, patient experience and reduce unnecessary cost and utilization: right care, right place, and right time.
• Assist patient in advanced care planning to complete Advanced Directives.
• Document all communications with patient and/or care team in electronic medical record.
• Perform coordination of services for disabled status and/or facilitate placement in post-acute facility for rehabilitation or long term care.
• Act as patient advocate to address primary physical and socioeconomic needs and link patient to appropriate community resources and services.

Benefits

• Competitive pay, incentives, referral bonuses and 403(b) with employer contributions (when eligible)
• Medical, dental, vision, prescription coverage, HSA/FSA options, life insurance, mental health resources and discounts
• Paid time off, parental and FMLA leave, short- and long-term disability, backup care for children and elders
• Tuition assistance, professional development and continuing education support

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level