Social Worker Care Coordinator - Population Health

In the capacity of a Social Worker, provide clinical care management services to identified eligible patients, coordinating care to obtain desired health outcomes, improve self-care abilities, and decrease unnecessary cost of care. Work as a member of Interdisciplinary Team (IDT) along with the Ambulatory Care Manager (ACM) and Care Coordinator to ensure the assigned patient’s individual needs are identified and addressed in a timely manner. Perform standardized comprehensive needs assessment, identifying and addressing barriers to care and aligning patients with available benefits and resources. 

This is a remote position supporting OH, KY, and IL.

Essential Job Functions

• Maintain a caseload of patients according to department policies.

• Identify, enroll and manage patients in program for Complex Case Management.

• Develop and implement care plans to maximize wellbeing with periodic review and update according to department protocols.

• Collaborate with ACM, PCPs, Specialists, and Hospitalists to effectively implement a patient-centered care plan.

• Perform situational and family assessment of social determinants of care and develop goals as part of the comprehensive care plan.

• Perform patient outreach according to established protocols and document in electronic medical record.

• Identify, execute, and track needed referrals to care and community resources.

• Provide resource management to improve care, patient experience and reduce unnecessary cost and utilization: right care, right place, and right time.

• Assist patient in advanced care planning to complete Advanced Directives.

• Document all communications with patient and/or care team in electronic medical record.

• Perform coordination of services for disabled status and/or facilitate placement in post-acute facility for rehabilitation or long term care.

• Act as patient advocate to address primary physical and socioeconomic needs and link patient to appropriate community resources and services.

This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job related duties as required by their supervisor, subject to reasonable accommodation.

Employment Qualifications

Education Qualifications

Bachelor’s Degree (required)

Bachelor’s or Master’s Degree in Social Work (preferred)

Licensing/ Certification

Master’s Degree or Licensure as required by state of practice (required)

Case Management certification, LSW or LCSW (preferred)

Minimum Qualifications

Minimum Years and Type of Experience

2-3 years acute care, home health or case management experience

Other Knowledge, Skills and Abilities Required

Excellent interpersonal communication and negotiation skills. Strong analytical, data management and computer skills. Demonstrate basic knowledge of healthcare and health education across the lifespan in a practice health setting. Ability to work with individuals, groups and families. Familiarity and knowledge of Community Resources. Flexibility to work non- traditional hours. Works well in a Team Setting. Personal computer skills.  Experience with database entry, EMR documentation, Power Point preferred and basic Excel skills. Highly organized and detail oriented. Accepts responsibility and follows through on projects and activities

Other Knowledge, Skills and Abilities Preferred

Demonstrated success in improving the health of a distinct population of patients in the ambulatory or community setting