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 the 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.

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.
  • Experience with database entry, EMR documentation, Power Point preferred and basic Excel 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)
  • 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, HAS/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

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What This Job Offers

Job Type

Full-time

Career Level

Mid Level

Number of Employees

5,001-10,000 employees

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