Description

JOB SUMMARY

The Licensed Social Worker works in collaboration with physicians, behavioral health clinicians and other staff at The Wright Center for Community Health to address barriers to medical and behavioral health care. The Licensed Social Worker addresses complex social needs of the underserved, uninsured, or under insured community members. This role serves in an expanded clinical role to collaborate with community members, Primary Care Providers, Behavioral Health Providers, dental, community agencies, insurance companies, and other health/community related entities to provide a model of care that ensures the delivery of quality, efficient, and cost-effective healthcare services. The Licensed Social Worker‘s expertise is sought to assess, develop and implement member care plans as it relates to addressing the social determinants of health and optimizing the members‘ physical and psychosocial health status. This is to ensure the member of the program has the resources necessary to achieve their highest level of functioning. Community outreach, such as home visits, health screenings and events may be required. This position requires flexible working hours including evenings, weekends and holidays. The Licensed Social Worker will work additionally as a Collaborative Care and Integrative Care Social Worker and work/coordinate the psychiatric collaborative model of care.

REPORTING RELATIONSHIPS

This position reports to the Director Behavioral Health Services. No other positions report to this position.

DUTIES & ESSENTIAL JOB FUNCTIONS

• Works with program leadership in the design, implementation, and evaluation of the programs objectives to the underserved, uninsured, underinsured, and newly insured populations
• Assists with state required functions for Medicaid members including Age Out Transition Procedure and resources for members in substitute care, waiver programs or facing an emergency placement situation
• Assists with developing coordinated care plans for members with complex medical/social/behavioral health needs. Fosters a collaborative team approach by working with the member, family, primary care provider, behavioral health clinician, community agencies, and other members of the treatment team to ensure coordination of services
• Assist to identify outreach, wellness and education planning needs of the community member and communicate findings to the treatment team
• Coordinates referrals between and among physical, behavioral and dental health providers and other community resources to improve overall community member outcomes. Ensures appropriate clinical management information is shared with peers, providers and outside agencies in a timely fashion while securing system privacy standards
• Provides outreach, including telephonic, meetings or oral presentations, to community healthcare agencies/resources
• Works closely with members to appropriately apply insurance benefits or obtain insurance benefits. Serve as a resource for the member and the healthcare team
• Maintains required documentation for all program related activities. Collect data and utilize data to adjust the care plan when indicated
• Acts as a patient advocate in order to coordinate required services or to resolve emergency problems in crisis situations. Provides individual and/or family education/counseling to assist in establishing members' overall wellbeing
• Conducts in-home member assessments for high risk or complex cases in collaboration with Practice Manager, Case Managers, contracted Home Health Agency and physician
• Utilizes evidenced based counseling techniques such as motivational interviewing and solution focused skills with focus on conflict resolution, assertiveness, problem solving, and decision making to assist member with effectively negotiating the healthcare continuum
• Documents patient encounters and contacts made on behalf of patients in EMR; completes and submits monthly reports; maintains comprehensive electronic patient files, which include patient notes, release of information, assessments and other medical documents acquired on behalf of the patient
• Educates patient on the proper use of the Emergency Department and provides information for alternatives. Coaches patients in effective management of their chronic health conditions and self-care. Assists patient in understanding care plans and instructions. Motivates patients/patients to be active and engaged participants in their health and overall wellbeing. Connects with Hotspotting Teams to connect patients with enabling services
• Provides support and advocacy during initial medical visit or when necessary to assure patients' medical needs and referrals required are being conveyed. Follows up with both patients and providers regarding health/social services plans
• Continuously expands knowledge and understanding of community resources and services. Facilitates patient access to community resources, including locating housing, food, clothing, prenatal classes, parenting, and relevant mental health services. Assists patients in utilizing community services, including scheduling appointments with social services agencies and assisting with completion of applications for programs for which they may be eligible
• Facilitates communication and coordinate services between providers and the patients/patients. Coordinates and monitors services, including comprehensive tracking of patients' compliance in relation to care plan objectives
• Works collaboratively and effectively within a team. Establishes positive, supportive relationships with participants and provides feedback to other members of the team. Builds and maintains positive working relationships with the patients, providers, care managers, medical residents, and office staff. Works to reduce cultural and socio-economic barriers between patients and institutions
• Attends weekly huddles and morning/afternoon mini huddles
• Work with HumHealth and document all encounters for both face-to-face and non-face-to-face interactions.
• Implements and works with the psychiatric collaborative model of care, coordinating care between the primary care and psychiatry residents/attendings on a consultation basis
• LSW will continue to follow up with patients who are being treated by medical with psychiatric or addiction histories on both face-to-face and non-face-to-face interactions. LSW will stay in communication with patients while the patient is in and out of office for care coordination. All interactions will be documented in HumHealth and copied into Medent
• Learn and become comfortable with the psychiatric collaborative care model. See patients who consult to psychiatry and who are seeing both psychiatry and medical

Requirements

QUALIFICATIONS 

• Master’s degree
• Pennsylvania Social Work licensure required
• Must possess valid PA driver’s license
• Current BLS Certification
• Both adult and pediatric specific experience required
• Knowledge of the basic concepts and principles of managed care required
• Knowledge of community resources required
• General computer knowledge and capability to use computers required
• Demonstrates the ability to interact in an effective manner with practitioners, the interdisciplinary healthcare team, community agencies, patients, and families with diverse opinions, values and cultural ideas
• Demonstrates ability to work autonomously and be directly accountable for practice
• Demonstrates ability to influence and negotiate individual and group decision-making
• Demonstrate the ability to function effectively in a fluid, dynamic, and rapidly changing environment
• Demonstrate leadership qualities including time management skills, verbal and written communication skills, listening skills, problem solving/decision-making skills, work delegation and work organization
• Demonstrates ability to be self-directed, flexible, and committed to the team vision
• Demonstrates teamwork, initiative and willingness to learn, accepts and respects diversity without judgment, and demonstrates strong customer service values

PACE Card Metrics

• 70% of clients are up to date with screens/ assessments per month
• Complete and submit all required reporting on time 100% - Verified by confirmation email from PA DOH
• Accurately document all case notes and services in MEDENT within 1 business day of client visit/contact
• 100% of assigned COE clients will be scheduled for an intake within 1 business and must have detailed documentation for those that were not
• 50% of COE clients will be retained in care for 60 days

The physical demands and work environment described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

*COVID-19 Vaccination Required*