Social Worker

Upperline Health•Austin, TX

34d•Remote

About The Position

Upperline Health is seeking a Social Worker who will be responsible for providing supportive and medical social services to patients and their families in the home. This will include a range of tasks such as directly providing support to Upperline's patients and families in the home as well as coordinating patient transition from facility to the home. The Social Worker assists the medical team in completing comprehensive psycho-social assessment to identify issues related to social determinates of health and collaborate in care plan development as a vital part of the interdisciplinary team to address individual patient's unique psychosocial needs, health status, and overall goals and values. Ideal candidates will have experience working with Medicare patients. Most importantly, candidates must demonstrate compassion for patient needs, have great attention to detail and thrive in a collaborative environment.

Requirements

Master's degree in social work from an accredited institution is required
Active licensure in California and Texas; with ability to obtain licensure in other states as deemed necessary
Minimum of 3 years social work experience required, preferably in a centralized care management team environment
Strong customer-service orientation
Patient, compassionate and professional demeanor required
Exceptional organizational skills and ability to multi-task
Self-starter with an entrepreneurial spirit and demonstrated problem-solving skills
Strong writing, Word, Excel, and database management skills
Extremely strong work ethic
Experience working in a fast-growing, rapidly changing environment

Nice To Haves

Experience working with Medicare patients
Prior healthcare experience serving chronically ill patients living with limited resources, serious emotional disturbance, and/or mental illness preferred
Telephonic case management or care coordination experience preferred

Responsibilities

Assess and provide intervention to address patient and family physical and psychosocial needs in collaboration with the interdisciplinary team
Communicate with other Upperline clinical team members, patient's other physicians and patient's other medical providers to coordinate optimal care and resources for the patient and his or her family, including social support and transportation needs, financial counseling, identifying non-clinical community resources, mitigating family dynamics and patient compliance issues, and assisting patients in logistically accessing available healthcare services
Assess, identify and close clinical and non-clinical gaps in patient care
Appropriately triage and escalate routine, urgent and emergent patient calls
Document social work assessments, care plans, and interventions
Provide brief, targeted counseling and intervention for psychosocial, emotional issues related to social determinants of health
Collaborate with field-based NPs and physicians to develop and implement effective treatment plans and interventions for complex patient care issues
Identify community resources and assist Upperline's patients and families in accessing those resources
Complete various clinical and administrative tasks
Participate in weekly interdisciplinary team meetings
Complete other related duties as deemed necessary by Upperline Health