Social Worker (MSW) - Full Time - 8AM-4PM - M-F - Morristown, NJ

Atlantic Health System•Morristown, NJ

7d•$33 - $59•Onsite

About The Position

The Care Coordination MSW Social Worker works in collaboration with a multidisciplinary team of clinicians as part of the Care Coordination program to provide high quality, outcome-based, patient-centered care and address the social drivers of health to support safe transitions of care across the continuum for patients and families throughout Atlantic Health System.

Requirements

Master of Social Work (MSW) degree
Experience in care coordination
Knowledge of social drivers of health
Ability to address social and economic barriers to health outcomes
Proficiency in psychosocial assessment and intervention
Experience with care transitions
Understanding of best practices in patient-centered care
Culturally-sensitive and inclusive intervention skills
Ability to develop and implement care plans
Experience with telephonic/virtual patient support and counseling
Accurate and timely documentation skills
Strong collaboration and communication skills
Knowledge of community agencies and resources
Patient advocacy and navigation skills
Ability to attend meetings and training sessions
Willingness to participate in educational programs relevant to practice area

Nice To Haves

Experience working with high-cost/high-risk patients
Familiarity with SDOH screening tools
Experience in behavioral health or substance misuse support
Experience with long-term care planning
Experience providing consultative support to community health workers

Responsibilities

Patient assessment, referrals, intervention (60%)
Documentation (20%)
Meetings, program development (10%)
Collaboration with inside/outside agencies (10%)
Support high-cost/high-risk patients to address barriers to care and navigation challenges across the care continuum by prioritizing health and SDOH needs, addressing gaps in internal and external resources, and sustainable connections to medical homes and sustainable social supports to improve the patient experience, achieve better health outcomes, decrease avoidable cost and utilization, and increase the utilization of preventative care and healthy behaviors to improve health.
Provide psychosocial assessment, sustainable care transitions, and structured support to help address social and economic barriers to positive health outcomes and empower patients to set and achieve their individualized health goals. Apply best practice interventions based upon care standards and referral and linkage to services to ensure behavioral and psychosocial needs are addressed, including but not limited to: social needs, financial stressors, difficulty coping, behavioral health concerns or substance misuse, abuse and neglect, interpersonal violence, homelessness, functional decline, frequent ED visits or hospitalization, need for long-term care planning, etc.
Maintain best practices, process systems, and key performance metrics to provide effective outcome-based, patient-centered care with a focus on culturally-sensitive and inclusive interventions, equitable access to care, and reduction in health disparities. Conduct psychosocial assessment, social determinants of health screening and referral, and develop a plan of care in alignment with individual needs, values, and goals of the patient. Provide individual telephonic/virtual support and counseling to patients, using appropriate therapeutic techniques and evidence-based theories to guide patients toward healthy coping, self-management, and overall wellness. Maintain accurate and timely referral response, assessment, intervention, and documentation, according to department workflow and policy.
Ensure ongoing collaboration and communication with the larger interdisciplinary Care Coordination team, AHS/ACO practices, providers, and care team members to comprehensively address evolving psychosocial needs, medical needs, and plan of care. Maintain a current knowledge base of community agencies and key contacts and assist with patient advocacy, navigation, and engagement with sustainable medical, social, insurance and benefit systems.
Regularly attend and actively participate in assigned intradisciplinary and interdisciplinary forums, administrative meetings, staff meetings, supervisory sessions, and in-service training. Provide consultative support for department community health workers through education, training and one to one case oversight. Annually participate in a minimum of 3 educational programs on topics relevant to practice area.
Other tasks as required by manager, director, or leadership.

Benefits

Medical, Dental, Vision, Prescription Coverage (22.5 hours per week or above for full-time and part-time team members)
Life & AD&D Insurance
Short-Term and Long-Term Disability (with options to supplement)
403(b) Retirement Plan: Employer match, additional non-elective contribution
PTO & Paid Sick Leave
Tuition Assistance, Advancement & Academic Advising
Parental, Adoption, Surrogacy Leave
Backup and On-Site Childcare
Well-Being Rewards
Employee Assistance Program (EAP)
Fertility Benefits, Healthy Pregnancy Program
Flexible Spending & Commuter Accounts
Pet, Home & Auto, Identity Theft and Legal Insurance