Social Worker (MA/MSW)

UHS•Reno, NV

18h•Hybrid

About The Position

Prominence Health is a value-based care organization that works with affiliated health systems and independent providers to improve outcomes and the patient and member experience. The Social Worker collaborates with the interdisciplinary care team to support members’ transitions from acute or post-acute care settings to home and uses the social work general practice model to improve transition outcomes. The role also engages outpatient members who need resources to reduce the risk of poor health outcomes, frequent emergency department visits, and hospital readmissions. The Social Worker receives referrals or identifies hospitalized high-risk and complex members who need social services, then communicates with entities involved in their care to promote coordination. Inpatient work includes assessments, educating members and families about available resources, identifying discharge concerns, and anticipating gaps in care. Encounters are intended to prepare members and caregivers for post-discharge needs and help them take an active role in managing care. The Social Worker may also organize support groups, counsel family members, conduct programs, and develop or advise on social policy and community health issues. The Social Worker follows the professional scope and standards applicable in the state where the member resides. The role also participates in implementation and operation of the SNP CM program and supports compliance of the model of care with applicable CMS, state Medicaid, and NCQA requirements. This is a hybrid position in Reno, Nevada, and requires being physically in Reno to see members in the hospital daily.

Requirements

Master’s degree in Social Work.
At least one year of experience in medical social work; hospital, hospice, transitional, or inpatient case management experience is preferred.
Active Licensed Clinical Social Worker license in Nevada, Texas, and/or Florida.
Ability to obtain licensure in various states.
Experience working with Medicare and Medicaid populations.
Knowledge of social and physical factors affecting functional status at discharge and of community resources for post-discharge clinical and social needs.
Ability to communicate effectively in English, verbally and in writing, for Nevada, Texas, and Florida markets.
Ability to communicate effectively in Spanish for Texas and Florida markets and/or Tagalog for the Florida market, depending on licensure state and employment location.
Proficiency in gathering and interpreting empirical evidence and developing recommendations, action plans, and interventions to improve organizational strategy.
Ability to manage multiple projects simultaneously through initiation, follow-through, and completion.
Ability to research, analyze, and interpret state and federal regulations related to health insurance and healthcare.
Ability to communicate project background, objectives, activities, evaluations, conclusions, and recommendations verbally and through technical writing.
Critical thinking, problem-solving, and complex information analysis, interpretation, and evaluation skills.
Ability to work independently with minimal supervision.
Ability to maintain effective collaborative working relationships with staff.
Resourcefulness, attention to detail, and ability to assimilate and analyze varied information while working under deadlines with staff at different levels.
Strong project management skills.
Computer skills with Smartsheet, SharePoint, Microsoft Office (Word, Excel, and PowerPoint), and database software.
Ability to work in a hybrid position based in Reno, Nevada, with daily in-person hospital visits to members.

Nice To Haves

Preferred certification: CCM, C-SWCM, or CMCP.
Knowledge of Medicare and Medicaid processes and compliance standards is preferred.
Hospital or hospice social work experience, or transitional or inpatient case management social work experience, is preferred.

Responsibilities

Collaborate with interdisciplinary care team members to facilitate members’ transitions from acute or post-acute care settings to home.
Use the social work general practice model to affect transition-to-home outcomes for members.
Engage outpatient members who need resources to help avoid poor health outcomes, frequent emergency room visits, and hospital readmissions.
Receive referrals or identify hospitalized high-risk and complex members in need of social services.
Communicate with entities involved in members’ care to promote and maximize care coordination.
Conduct inpatient assessments and educate members and families about available resources.
Identify member-level discharge concerns and anticipate potential gaps in care.
Prepare members and caregivers for post-discharge needs and empower them to participate actively in managing care.
Organize support groups or counsel family members during inpatient stays or after discharge, as needed.
Plan and conduct programs, and develop or advise on social policy addressing social problems and community health issues.
Follow the Social Worker Scope and Standards of Professional Practice in the state where the member resides.
Participate in successful implementation and operation of the SNP CM program and help ensure the model of care meets or exceeds applicable regulatory and accreditation requirements.
Be physically present in Reno to see members in the hospital daily.