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. They advocate 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.

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
• If applicable, the 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

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.
• 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.

Job Type: Full-time

Pay: $70,000.00 - $80,000.00 per year

Benefits:

• 401(k) matching
• Dental insurance
• Flexible spending account
• Health insurance
• Health savings account
• Paid time off
• Parental leave
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Education:

• Master's (Required)

Experience:

• Community Social work: 2 years (Required)

Work Location: In person