Social Worker or Population Healthcare Coordinator. - Chronic Care Management

Position Overview

We are currently seeking a dedicated Social Worker to join our Chronic Care Management team. This professional is tasked with the delivery of high-quality care, ensuring a positive customer experience, and upholding the principles of responsible resource management. They achieve this by orchestrating psychosocial support and services tailored to the individual needs of patients, in close cooperation with the patient's family and healthcare team. Operating with a high degree of autonomy, the social worker conducts comprehensive evaluations to pinpoint the social factors affecting a patient's health. They are committed to offering empathetic and attentive care to those in primary care settings. Accepting this position requires an appreciation for the necessity of swift action, coupled with an exceptional capacity for organizing and prioritizing tasks in a dynamic and expanding healthcare landscape.

Qualifications

• A bachelor's degree in social work LCSW/LMSW
• Valid State Driver’s License.

Experience

• Previous experience in social work or human services.

Skills

• Strong interpersonal and communication skills.
• Empathy and sensitivity to the needs of diverse populations.
• Primary Care populations.
• Knowledge of state regulations and standards related to client treatment, patient rights, and client/ patient confidentiality.
• Possess proficient ability and experience in computer applications, specifically electronic medical records (EMR) systems.
• Possess proficient computer application abilities to record time, obtain work directions, and complete assigned duties.
• Proficient in Microsoft Office Suite, including Excel, Word, Outlook, and PowerPoint.

ESSENTIAL JOB DUTIES/RESPONSIBILITIES:

• The professional will evaluate clinical data to identify patients eligible for Chronic Care Management (CCM) services and determine the suitability of enrollment.
• Referral to community resources: Connecting the patient to community resources and social services that can address their specific social needs, such as food assistance programs, housing support, transportation services, and financial assistance programs.
• Care coordination with social service agencies: Collaborating with social workers (in-house social worker), case managers, and community organizations to coordinate services and support for the patient, ensuring they have access to the necessary resources and assistance.
• Referring the individual to mental health services, counseling, or therapy to address mental health concerns, stress, anxiety, or depression that may be impacting their health and quality of life.
• Financial assistance and insurance enrollment: Assisting the individual in navigating financial challenges, accessing health insurance coverage (we have an in-house insurance broker that can assist with the process), applying for benefits, and securing financial assistance programs to alleviate financial barriers to care.
• Social support and community engagement: Connecting the individual to social support networks, peer groups, or community activities to reduce social isolation, build social connections, and enhance their overall social well-being.
• Working closely with one or more physician practices, identifying patients with significant morbidity, risk, and healthcare utilization, and to address gaps in care. The goal is to collaborate with providers to enhance patient outcomes and the quality of care.
• The role includes participating in or leading team meetings to create actionable plans for delivering high-quality care.
• When a patient is not meeting treatment goals, deviating from the care plan, or missing critical appointments, this role involves identifying obstacles and addressing them.
• This role requires facilitating effective communication and collaboration between the patient and relevant parties to achieve health goals and optimize patient outcomes.
• Documentation practices must be maintained to meet audit requirements and comply with quality standards, ensuring patient confidentiality in accordance with HIPAA regulations.
• Additionally, the individual will be responsible for completing various projects, assignments, and duties as needed.

Job Type: Full-time

Work Environment

• This position is based in a high-rise office suite with amenities including an on-site café, conference facility, and fitness center.
• Regular working hours with the possibility of some weekend shifts as needed.

We Offer

• Competitive compensation package.
• Comprehensive benefits including health insurance, retirement plans, and paid time off.
• Supportive work culture focused on professional development and continuing education.
• Opportunity to work in a growing field with a focus on improving patient outcomes.

Tipo de puesto: Tiempo completo

Sueldo: A partir de $54,000.00 al año

Lugar de trabajo: Empleo presencial