Social Worker

Summary

The primary role of the Social Worker is to assess the psychosocial needs of beneficiaries and provide solution-focused care coordination to address issues that impede their ability to adhere to their healthcare treatment plan. The Social Worker identifies, evaluates, and provides management of services for beneficiaries with complex, catastrophic, SDOH (Social Determinants of Health) and/or psychosocial issues to promote quality, effective outcomes throughout the care continuum. The Social Worker ensures compliance with state and federal health plan requirements, Medicare guidelines and standards, and acts as a liaison to coordinate and collaborate care with physicians, family, and other providers while always remaining an advocate for beneficiaries, putting them at the center of care delivery.

Essential Duties and Responsibilities

• Perform comprehensive evaluations and document findings in a concise/comprehensive manner that is compliant with documentation standards for the Center for Medicare and Medicaid Services (CMS)
• Performs psychosocial beneficiary assessments in multiple settings to include but not limited to the beneficiary’s home, the PCP/specialists clinic, hospital, and/or skilled nursing facility as needed
• Assist with implementing new clinical programs in collaboration with the VP, Director of Clinical Operations and Clinical Nurse Educator
• Assist with development and creation of clinical programs specific to social determinants of health in collaboration with VP, Director of Clinical Operations and Clinical Nurse Educator
• Coordinates identified needs utilizing federal, state, and local community resources, as available
• Coordinates with external and internal teams to minimize obstacles and increase beneficiary and provider satisfaction
• Cooperate with health care professionals to evaluate beneficiaries’ socioeconomical and physical condition and to assess client needs
• Advocate for beneficiaries to resolve crises
• Assess beneficiaries needs and/or care plan treatments
• Interview beneficiaries to gather information about their backgrounds, needs, or progress
• Intervene in crisis situations to assist beneficiaries
• Evaluate effectiveness of Care Plan and make necessary adjustments
• Coordinate PCP follow ups (call to help ensure they make their appointments) or set an appointment from the beneficiary’s home
• Communicate directly with PCP and/or specialists regarding any problems, or therapy changes
• Provide emotional and physical comfort and safety of beneficiaries, taking into consideration their rights and cultural backgrounds
• Provide education, monitoring of health needs, and coordinating of community resources
• Participate in case conferences, team meetings, staff meetings and Performance Improvement activities as assigned
• Facilitating beneficiary empowerment and quality of life by promoting educated, independent beneficiary choice on all aspects of care
• Identifying opportunities for health promotion and illness prevention
• Adhere to all policies and procedures including but not limited to the HIPAA Privacy rule
• Adheres to all policies and procedures including HIPAA
• Maintains professional licensure and other requirements
• Performs other duties as assigned

Knowledge, Skills and Abilities

• Documentation Skills
• EMR proficiency
• Analyzing Information
• Critical Thinking Skills
• Decision Making
• Verbal and written communication proficiency
• People Skills
• Conflict resolution
• People Management
• Integrity, compassion
• Bilingual: Spanish and English

Minimum Education and Experience

• Master’s degree in social work from an accredited school
• 3 years of social work experience in a healthcare and/or community environment
• Proficient in MS Office Suite to include Word, Excel, Notes, Outlook
• Knowledge of Social Work theory and practice as it pertains to people of all ages
• Knowledge of population health management engagement strategies
• Knowledge of Medicare/Medicaid populations and community-based resources
• Experience working with medically complex patients
• Experience in crisis intervention, de-escalation, and short-term counseling
• Experience addressing barriers to care, including social determinants of health (SDOH)

Job Location

• Hybrid, Onsite 3 days a week. As needed in-person attendance at corporate office for meetings, events, and workshops
• Local road travel required, 25–50% within Miami-Dade and Broward counties. Field visits may include patient homes, clinics, hospitals, and skilled nursing facilities