Social Worker

ChenMed•Cleveland, OH

110d•Onsite

About The Position

The Social Worker (SW) is a member of the care treatment team including the PCP, other Medical Specialists, LCSW/BHS, and Case Managers. The incumbent in this role is responsible for providing psychosocial assessment, social case work and linkage to community resources for patients who have chronic, life threatening or altering diseases and disorders. He/She advocates for services and resources for the underprivileged and victims of abuse, neglect, or other difficult personal situations to help them maintain an optimum level of health. Social Workers will adhere to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance, and policies and procedures as defined by industry standards and the enterprise.

Requirements

Keen business acuity and acumen
Full knowledge and understanding of general Social Worker functions, practices, processes, procedures and techniques
Knowledge of social services documentation procedures and standards
Knowledge of community health services and social services support agencies and networks
Knowledge of normative changes (e.g., sensory, cognitive, psychosocial) associated with aging for high-risk patients
Knowledge of advance care planning and palliative care, and related skill in addressing advance care planning
Ethical practice behavior consistent with ChenMed policies and professional standard
Skill in psychosocial interventions with challenged caregivers/family systems of high-risk patients
Appropriate utilization of community-based resources
Teamwork skills in care coordination with patients, family systems, staff, and external providers
Ability to work autonomously is required
Ability to monitor, assess and record patients’ progress and adjust accordingly
Ability to communicate technical information to non-technical personnel, and with patients and/or their family systems
Strong interpersonal, communication and critical thinking skills and the ability to work effectively with a wide range of constituencies in a diverse community
Demonstrated ability to provide care effectively and sensitively to people from different cultural groups
Ability to create a collaborative relationship to maximize the patient’s/family’s ability to make informed decisions
Proficiency in written communication: documentation is clear, concise, accurate, provides meaningful communication and is consistent with company policy and regulatory requirements
Proficiency in technology, including the utilization of Electronic Medical Record platforms for care coordination
Proficient in Microsoft Office Suite products including Word, Excel, PowerPoint and Outlook, plus a variety of other word-processing, spreadsheet, database, e-mail and presentation software
Ability and willingness to travel locally, regionally and nationwide up to 30% of the time
Spoken and written fluency in English
This job requires use and exercise of independent judgment

Responsibilities

Conducts timely and appropriate assessment and needs identification, prioritizing patients on the PCP’s High Priority Patients (HPP) and Top 40 patient lists. Assesses the patients for psychosocial, financial, family issues, palliative care/end of life issues, home safety, etc. that contributed to hospitalization.
Dialogues with PCPs in order to support and advise concerning social needs and resources available.
Conducts appropriate assessment of needs and financial benefit eligibility.
Assesses patients for Medicaid criteria and assists with application process as needed.
Assists patients to obtain community resources/services as appropriate, e.g. meals, medications, housing, daycare, DME, HHA. etc.
Serves as care coordinator, linking patients with internal and external resources, prioritizing patients on the PCP’s HPP and Top 40 patient lists.
Facilitates connections to community resources as identified by the patient’s SDoH Wellness Screening.
Works with patient, family, and case manager to facilitate applications for higher level of care.
Works to provide self-management support and ongoing phone contact with patients.
Maintains an accurate repository of social wellness tools for the care team’s awareness and utilization.
Maintains communication with other healthcare team members by attending appropriate meetings (i.e. weekly Super Huddles and Transitional Care Team meeting.).
Provides consultation in an integrated health care environment regarding social determinants of health and community resources.
Maintains timely, accurate, thorough and appropriate documentation/reports per company policies and procedures. Initial psychosocial assessments will be completed withing 48 hours. All follow up visits phone calls and collaborative contacts will be documented within 24 hours. Assures documentation meets billing guidelines.
Works closely with the transitional care team to secure the appropriate level of care post hospital/SNF discharge. Further interventions may be conducted in the center, by phone call or patient’s home.
Performs other duties as assigned and modified at manager’s discretion.