Social Worker - TriHealth Center for Health Equity

TriHealth•Cincinnati, OH

11d•Onsite

About The Position

Are you passionate about advancing health equity and helping patients overcome barriers to care? Join TriHealth's Center of Health Equity as a Licensed Clinical Social Worker (LCSW) and make a meaningful impact on the health and well-being of our community. In this collaborative role, you'll partner with providers and interdisciplinary teams to support patients with complex medical, behavioral, and social needs. Through care coordination, resource navigation, crisis intervention, and patient advocacy, you'll help address social determinants of health while empowering individuals and families to achieve better health outcomes and an improved quality of life.

Requirements

Bachelor's Degree in Social work, Addictions, Counseling (Required)
3 - 4 years years experience (Required)
LCSW- License Clinical Social Worker (Required)

Responsibilities

Assesses, plans, implements, monitors, and evaluates delivery of individualized, patient-centered care with the goal of optimizing the patient’s health status through connection with available support systems, community resources, care coordination with necessary specialists, and patient education. Develops plans to address psycho-socio-economic and/or behavioral issues.
Communicates and collaborates with PCP and clinical staff regarding the patient’s psycho-social barriers to health maintenance and assist in coordinating and supporting referrals to indicated services. Interacts with clinical and medical personnel across all hospital inpatient and outpatient service lines to ensure collaboration across care settings and meaningful integration at transition points.
Contributes to individualized care for identified patients, focusing on psychosocial assessment and setting goals to meet identified needs. Assess progress toward goals, support evidence based clinical protocols and plan of care and addresses barriers to progress. Completes required documentation of above.
Works with high-risk patients to provide targeted interventions to improve health outcomes. Coordinates care across settings and helps patient/families understand health care options. Promotes patient self-management support with a focus on empowering the patient/family to build capacity for self-care in order to achieve optimal health and independence.
Utilizes registries, reports and tools to identify target populations and patients.
Plans for and manages a panel of patients with chronic/complex disease(s); plans interventions appropriate to patients' diagnoses, age, abilities and resources; establishes and implements patient directed learning and supports disease self-management care plan for patient/significant others to enhance therapeutic outcomes.
Participates in quality improvement initiatives; activities may include data collection, chart review, interdisciplinary collaboration, analysis of patient data and inter-professional staff meetings.
Address identified social determinants of health
Complete comprehensive social needs assessment
Crisis intervention
Resource coordination
Benefits navigation
Housing, food, transportation, utility support
Behavioral health referrals
Patient advocacy