Social Worker, LSW- Population Health

Jefferson Health Plans • Philadelphia, PA

1d

About The Position

The Social Worker will facilitate patient continuity of care throughout the healthcare system. S/he collaborates with the Primary Care team to provide leadership in issues of outcomes management, disease management and prevention, and development of improved strategies to benefit high risk patients. This role will engage patients and encourage them to take an active role in their health by providing them with the tools necessary to make healthy lifestyle choices and adopt life-long healthy behaviors. This role will serve as an advisor to the clinical team for health related social needs. Functions as an advocate for the patient where applicable, and work collaboratively with internal/external resources to ensure the needs of our patients are consistently met.

Requirements

• Knowledge of: Medical terminology and disease process; Community resources; Insurance regulations and requirements
• Skill in: Work with multidisciplinary teams, outside resources, patients/families/significant others
• Ability to: Establish an appropriate plan to safely discharge patients to the next level of care
• Graduate from an accredited Masters of Social Work program required.
• 5 years’ experience in hospital or community clinic, home care, discharge planning, and/or case management required
• Minimum 2 years’ experience working with frail or elderly population
• Strong behavioral health background

Nice To Haves

• 3 years’ experience in a managed care environment preferred

Responsibilities

• Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.
• Integrates evidence based practice, clinical expertise, patients, their family/designated care partner(s) preferences and cultural beliefs and values for delivery of optimal health care. Partners with patients, their family/designated care partner(s) in identifying learning needs and priorities and provides education in ways that is useful, understandable and affirming.
• Conducts psychosocial assessment/reassignment of patients/significant others relating to the social, emotional and cognitive capabilities of patients in relationship to their illness and health maintenance needs.
• Develops and implements a plan of intervention that addresses identified needs related to needs/problems identified during assessment.
• Compiles and discusses findings with support team to evaluate and manage geriatric conditions in the home.
• Performs psychosocial assessments that will identify applicable barriers, problems, goals, and interventions that will close gaps in care and address those needs and improve or maintain the health status of the patient, based on assessment of patient’s needs and environment
• Engages and counsels patient and family members to develop an individualized plan of care to promote healthy lifestyles, close gaps in care, and reduce unnecessary ER utilization and hospital readmissions. Develops and coordinate the individualized plan of care with the member, member’s family, providers and community agencies as applicable. Involves other staff to support the individualized plan of care based on identified needs of the patient
• Follow-ups with the patient according to established clinical program protocols and timeframes to monitor their status, evaluate the effectiveness of the individualized plan of care, and identify new needs. Modifies the individualized plan of care or case status based on the status of the patient.
• Documents activities in a timely and accurate manner; assuring all documentation complies with Jefferson’s quality standards, CMS standards, DVACO standards, etc.
• Provides counseling for patient/family/significant others to assist with coping with new diagnoses, chronic illness and palliative or terminal care
• Advocates for the patient and family throughout the entire episode of care. Functions as a resource to facilitate communication among the healthcare team and patient/family. Acts as a resource to patients and families to obtain necessary services
• Provides counseling and crisis intervention in cases involving child abuse/neglect, domestic violence, elder abuse, and institutional abuse. Provides interventions in cases regarding guardianship, mental health placement, advance directives, trauma, and substance abuse.

Benefits

• Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts.
• Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service.
• All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

What This Job Offers

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