We’re unique. You should be, too.

We’re changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy?

We’re different than most primary care providers. We’re rapidly expanding and we need great people to join our team.

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.

ESSENTIAL JOB DUTIES/RESPONSIBILITIES:

Needs identification and assessment:

• 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.

Medicaid and other benefit eligibility assessment:

• 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.

Resource coordination and intervention:

• 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.

  Communication.

• 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.

Timely and accurate documentation:

• 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.

Additional duties and responsibilities may include:

• 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.

KNOWLEDGE, SKILLS AND ABILITIES:

• 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

EDUCATION AND EXPERIENCE CRITERIA:

• BS degree in Social Work required
• Master’s Degree of Social Work (MSW) preferred
• A minimum of 2 years’ work experience in social work, case management, and/or discharge planning experience required
• A minimum of 2 years’ experience in a primary care setting preferred
• State Licensure at a Master’s Level is preferred but may be required (dependent on state)
• If applicable, incumbent must be compliant with the mandatory laws of state licensure at the Master’s level. If desired, clinical supervision for those working towards clinical license (LCSW) can be provided for this position