Social Worker

Upperline Health•Nashville, TN

About The Position

Upperline Health is seeking a Social Worker to provide supportive and medical social services to patients and their families in the home. The role includes directly supporting patients and families and coordinating transitions from healthcare facilities to home. The Social Worker assists the medical team with comprehensive psychosocial assessments, identifies issues related to social determinants of health, and collaborates with the interdisciplinary team on care plans that address each patient's psychosocial needs, health status, goals, and values. The role works with field-based nurse practitioners and physicians and may involve patients with chronic illness and limited resources. Experience with Medicare patients is valued. Candidates should demonstrate compassion, attention to detail, and the ability to work collaboratively.

Requirements

Master's degree in social work from an accredited institution.
At least 3 years of social work experience.
Strong customer-service orientation.
Patient, compassionate, and professional demeanor.
Exceptional organizational skills and ability to multitask.
Self-starter with an entrepreneurial spirit and demonstrated problem-solving skills.
Strong writing, Word, Excel, and database management skills.
Extremely strong work ethic.
Ability to work in a fast-growing, rapidly changing environment.

Nice To Haves

Experience working with Medicare patients.
Social work experience in a centralized care management team environment.
Healthcare experience serving chronically ill patients living with limited resources, serious emotional disturbance, and/or mental illness.
Telephonic case management or care coordination experience.

Responsibilities

Assess and provide interventions addressing patients' and families' physical and psychosocial needs in collaboration with the interdisciplinary team.
Coordinate care and resources with Upperline clinical team members, patients' physicians, and other medical providers, including social support, transportation, financial counseling, community resources, family dynamics, patient compliance, and access to healthcare services.
Assess, identify, and close clinical and non-clinical gaps in patient care.
Triage and escalate routine, urgent, and emergent patient calls appropriately.
Document social work assessments, care plans, and interventions.
Provide brief, targeted counseling and interventions for psychosocial and emotional issues related to social determinants of health.
Collaborate with field-based nurse practitioners and physicians to develop and implement treatment plans and interventions for complex patient care issues.
Identify community resources and help patients and families access them.
Complete clinical and administrative tasks.
Participate in weekly interdisciplinary team meetings.
Perform other related duties as deemed necessary by Upperline Health.