Social Worker (LPC/LCSW)

Odyssey House Louisiana•New Orleans, LA

19d

About The Position

Social Worker-Community Health Center Join our mission to provide a comprehensive continuum of care for people in Louisiana, encompassing primary care, behavioral health, and substance use disorder treatment. Help save lives at OHL! Job Summary Odyssey House Louisiana, Inc. is seeking a full-time Social Worker for the Community Health Center. The schedule is Monday-Friday 8am-5pm. The Social Worker will provide comprehensive assessment and diagnosis of behavioral health clients. The position will also assist primary care providers and Program Managers with implementing disease management programs; participate in the development, review, and evaluation of the family and/or client’s plan of care; utilize information from various sources to identify patients who would benefit from disease management and case management services; educate and engage patients in their own care management; identify social and/or medical barriers that impede health outcomes; link patients to appropriate levels of care/appropriate and supportive services; work collaboratively with a multidisciplinary inter-agency team to facilitate achievement of desired treatment outcomes, monitor patient ED and hospitalization utilization rates; and utilize an Internet based care management system to track patient progress and health outcomes.

Requirements

Master’s in Social Work
LCSW unencumbered licensure
Greater than 1 year Clinical/UM/Discharge Planning/Home Care/Social Work/Ambulatory experience
Current CPR certification
Excellent interpersonal, communication, and negotiation skills
Clinical competence in assigned area
Strong organizational and time management skills
Ability to work independently
Familiar with medication-assisted treatment and including opioid treatment programs.

Responsibilities

coordinate/facilitate patient care
provide direct care to patients within the Scope of Practice for which the provider is licensed
provide direct care to clients/patients to support the agency’s department
manage patient care under Best Practices, UDS recommendations, and as prescribed to maintain accreditation
conduct thorough documentation of visits and medical orders to support billing charges
complete billing components of visit to optimize revenue within dictated time frames
work collaboratively and maintains communication with patient care team (providers, nurses, etc.) to provide effective, timely, and appropriate patient care management
assist patients and providers to adhere to evidence-based treatment protocols for specific disease states
educate patients and helps to engage them in their own care management, provide asthma and diabetes education
monitor patient care by tracking patient charts, counsel patients during physician visits, follow up through telephone calls and home visits as needed, and utilize Internet based case management tracking system
meet directly with patient/family to assess needs and develop an individualized care plan as necessary
ensure/maintain plan consensus from patient/family, physician, and health care team
collaborate with relevant community-based social services and health care organizations (social workers, home health care, school nurses, hospice providers, etc.) to address patient needs/barriers to improved health outcomes and to secure necessary care and equipment
address/resolve system problems impeding progress
proactively identify and resolve delays and obstacles to expedite care
utilize advanced conflict resolution skills as necessary to ensure timely resolution of issues
collaborate and communicate with multidisciplinary team at all phases of planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, and teaching and ongoing evaluation
identify patients with need for Patient Assistance Program submission to pharmaceutical companies in order to offset the cost to patient (This includes assisting patient in filling out application, identifying needed documents to support income, assure provider licenses are submitted, application is signed by provider, manage the course of application, notify patient of arrival of medicine, and when need for refills occurs; log of applicants will be kept and submission of application and arrival of meds will be documented in log)
perform utilization management and quality screening for assigned patients
identify at-risk populations using approved screening tool(s) and follows established care and reporting protocols
monitor medical resource use on an ongoing basis and take action to achieve continuous improvement
refer cases and issues to PCP and follows up as indicated
follow up on referrals from PCP as appropriate
actively participate in clinical performance improvement activities
participate in development, implementation, evaluation and revision of disease management tools as a member of the clinical change team
attend local meetings as necessary
participate in training as necessary to successfully complete job responsibilities, including training in disease management protocols, care management strategies, use of network software programs, and data analysis skills
use data to drive decisions and plan/implement performance improvement strategies related to care management for assigned patients, including fiscal, clinical, and patient satisfaction data
collect special study data for specific performance and/or outcome indicators as determined by program
participate in discussions of key variances and outcomes that relate to areas of direct responsibility
use data in collaboration with other disciplines to ensure effective patient management
provide effective treatment planning and assist clients in successfully achieving goals
evaluate crisis situations and apply appropriate interventions
actively participate in meetings that support the integrated health care model to provide comprehensive care for clients
assist in the detection of “at risk” patients and development of plans to prevent further psychological or physical deterioration
assist the primary care team in developing care management processes including guidelines, disease management techniques, case management, and patient education to improve self-management of chronic disease
provide assessment, consultation, and brief intervention for psychological/psychiatric problems and/or disorders
teach patients, families, and staff, care, prevention, and treatment enhancement techniques monitor the site’s behavioral health program to identify and make improvement recommendations for problems related to patient service
perform other duties as assigned