RN/LCSW

Primary Functions:

• ·         Responsible for patient outreach, assessment, disease management, and care coordination to patients with high rates of medical and behavioral health utilization and/or psychosocial vulnerability ·         Assess patients through telephonic and eventually face to face encounters ·         Builds a collaborative relationship with patients and their identified support system to encourage care participation and improve self-management of needs ·         Utilize motivational interviewing to identify barriers and facilitate care plan compliance ·         Effectively educate patients about healthcare delivery, plan benefits and a variety of topics related to health, and community resources ·         Coordinates timely and appropriate implementation of assessments, care plans, and interventions for the identified patient population ·         Provide medication reconciliation and support ongoing adherence ·         Provide transitional care management ·         Identify and helps to align patient care and community resources to prevent hospital readmissions and Emergency Department visits ·         Document all activity in the documentation systems relevant to the role ·         Collaborate with the care team to achieve high-quality, low-cost outcomes for patients. ·         Interface and maintain positive relationships with key providers in the local hospitals, community practices, and organizations to ensure proper patient engagement and follow up ·         Achieve established productivity targets ·         Maintain compliance with the organization policies and procedures ·         Demonstrate the ability to adapt, innovate and lead in a fast-paced environment, where change is common ·         Passionate about making a difference in individual’s lives ·         Other duties as assigned

Qualifications:

• Requires a Master’s in Social Work
• Must have a current full licensure as a LCSW by the NC Social work Certification and Licensure Board
• Two years post master’s clinical experience is required
• Medical Social Work experience strongly preferred
• Knowledge of care management and quality principles are preferred
• Requires the ability to maintain confidentiality
• Must be able to interact with individuals of all cultures and level of authority

Additional skills required:

• Excellent and effective written and oral communication skills.
• Proficiency in Microsoft Office Outlook, Word, Excel, PowerPoint use and e‐mail communication.
• Ability to communicate clearly and succinctly.
• Dependable, manages time well; efficient and organized.
• Must be able to interact with individuals of all cultures and levels of authority.
• Requires the ability to maintain confidentiality.

Benefits:  

• 401(k)  
• Health, Dental and Vision insurance  
• Employee assistance program  
• AFLAC
• Paid time off