Medical Social Worker HOPP

Primary Function 

The Healthy Opportunities Pilots (HOP) is the nation’s first comprehensive program to test and evaluate the impact of providing select evidence-based, non-medical interventions related to housing, food, transportation and interpersonal safety and toxic stress to high-needs Medicaid enrollees.  Through the Healthy Opportunities Pilots, the North Carolina Department of Health and Human Services (NCDHHS) is dedicated to:

• Ensuring members can access Pilot services in a timely manner and in a way that meets their needs and improves their health.
• Demonstrating equity across all aspects of the Pilot program—including through ensuring diverse and equitable participation in the Pilots for Medicaid members and human service organizations.
• Strengthening community capacity to provide high-quality, member-centered services.

The Healthy Opportunities Pilots will cover the cost of 29 interventions.  These services were selected based on their potential to improve health outcomes and/or lower health care costs and address the housing, food, transportation, interpersonal violence and toxic stress needs of qualifying Medicaid members. To be eligible for and receive Pilot services, NC Medicaid Managed Care members must live in a Pilot region and have at least one qualifying physical or behavioral health condition and one qualifying social risk factor, as defined by the Department and CMS.  The EBCI Tribal Option partners with NCDHHS and the Human Service Organization (HSO) to deliver these services to the qualifying members of the EBCI Tribal Option (TO).  The team consist of the care manager, medical social worker and the utilization review personnel for the coordination of services for the member.  Other personnel may be involved in the activities as needed to complete the monitoring of need and the payment for the services obtained.  Here we will define the job description for the HOP Medical Social Worker.

The HOP Medical Social Worker is responsible for coordinating and managing these service delivery activities in order to assure meeting the needs of the client. The position also includes case management duties to assure clinically and financially responsible care. He/she maintains liaison with other departments, agencies, organizations, and community resources in determining appropriate resource utilization.

Job Description 

• HOP Medical Social Worker serves as the principle advisor and consultant to the Primary Care staff on all matters pertaining to services that are included in the HOP Pilot Program. provides a wide range of social work activities to eligible EBCI TO members. This may include being a liaison between local tribal, county, regional and state entities to ensure the meeting of members care needs or gaps in care.
• With the input of the member’s care manager, the HOP Medical Social Worker plans, provides and directs coordination of services to EBCI Tribal Option members and their families on an individual or group basis. Coordination of services may include, but are not limited to, assisting patients and families in arranging patient transfer and assisting with transportation issues, ensuring that food insecurities are addressed along with Intimate partner violence (IPV) issues and living in a toxic environment. 
• Coordination of needed services as determined from a developed plan of care and assessment of the member’s care manager.
• Through consultation, shares social evaluations and knowledge of patients, their families, and community resources with care managers assigned to the member.  
• Establishes and maintains liaison and close working relationships with county social services, related agencies and organizations in the service unit area, to secure services for EBCI Tribal Option members meet the needs of the individuals, along with the HOP Program Director. 
• Assists the care manager in developing an individual primary plan of care, and assist in assessing patients’ needs through interviews with patients, relatives, and others to obtain pertinent information.
• Responsible for enforcing HOP program policies and procedures.
• Ensures conformance to acceptable standards of HOP Program and Case Management practice, including all policies, procedures, rules, and regulations of the Cherokee Indian Hospital, JCAHO, CMS, and State Division of Medical Assistance.
• Attends daily multidisciplinary Huddles, confers with care management staff on services and Case Management problems, as well as, develops, and implements plans for corrective action.
• Will assist care management staff as needed with coordination of care and disposition of patients from the Primary Care.
• Interprets patient’s resource and case management needs to the Medical and Nursing staff and collaborates with them in the determining available resources. Maintains communication with Prepaid Health Plans (PHP) in determining plan of care and coordinates care with the patients’ Integrated Care Team.
• Assists in the responsibility of identifying providers or services needed to coordinate the patient’s care in the Primary Care setting, or upon discharge from the Cherokee Indian Hospital or regional facility.
• Performs completion of standardized tools, such as the Pilot Eligibility Service Assessment (PESA), documenting the member’s eligibility, service recommendations and service-specific eligibility criteria.
• Assesses whether a member meets the qualifying criteria to be eligible for HOP, and by utilizing a check list for completion of requirements of any of the 29 services that the member may be referred to.
• Recommend specific HOP services that can best address the member’s needs.
• Obtain verbal or written consent for HOP services
• Use the NCCare360 platform to document information and transmit to the appropriate service authorization team.
• Receive from Utilization Management (UM) staff, service authorization information in the member’s PESA and communicate the approval or denial to the member’s care management team
• Assist with the Pass-through services which are permitted for 30 days, without UM approval, for high value, low-cost services to meet the immediate needs of the member with expedited services.
• Use NCCare360 to refer members to authorized services within two business days of receiving authorization for the service/s
• Use NCCARE360 to monitor the HSOs acceptance of the referral and initiate the service
• Assist the care manager in updating the member’s care plan related to services provided and goals.
• Assist in coordinating with the HSO to assess the extent the services are meeting the needs of the member
• Assess the member’s services every 3 months to ensure the services are meeting the needs, and if not meeting the needs recommend new services of modify the former referral for services.
• Assess the member’s services every 6 months for their eligibility for the HOP services based on the qualifying criteria
• Assess for instances where the member’s services should be discontinued or when members must be disenrolled from HOP due to no longer needing services or no longer eligible for services through the program
• Communicate any changes to the member, update the member’s care plan, and generate new referrals via NCCARE360, as required, in cooperation with the member’s care manager.
• Maintains files and prepares reports on HOP and Case Management activities and areas for improvement for submission to the HOP Program Director and other appropriate groups.
• Maintains and promotes positive and constructive communications and activities within nursing services, other departments, tribal, and community agencies for purposes of coordinating and understanding of program goals.
• Participates in the development and implementation of Performance Improvement activities and participates or leads at least one Quality Improvement activity per year (PDSA).
• Attends meetings, planning sessions, committees, and serves on teams to promote quality and performance improvement.
• Actively participates with the Integrated Care teams in planning, organizing, and directing departmental services.
• Participates in various hospital committees as assigned.
• Performs other related duties as required.

Education/Experience/Minimum Qualifications 

• Bachelor’s Degree in Social Work.
• At least 2 years’ experience as a Social Worker, preferred. Prefer that experience reflect knowledge of Hospital Social Work.
• Current Basic Life Support (BLS) required for the position.  If applicant does not have current, must obtain within 6 months of hire.

Job Knowledge 

• Knowledge of the HOP policy and protocols as determined by NCDHHS and EBCI Tribal Option.
• Knowledge of principles, practices, techniques, and theories of social work in order to plan and provide activities for services within the HOP pilot to meet the physical, emotional, spiritual, and socio-cultural needs of patients of all ages; specifically, Infancy (Birth-1 year), Toddler and Early Childhood (2-5 years), Latency (6-9 years), Preadolescence (10-12 years), Early Adolescence (13-15 years), Adolescence (16-20), Adult (21-64 years), and Elderly (65- years).
• Knowledge of social services and its application to clinical practice.
• Knowledge of disease process, health care treatment and systems, and treatment protocols.
• Knowledge of health care financial management, provider payer mechanisms, business environment, and resource management.
• Knowledge of strategic planning, outcome measurement, quantitative methods and statistics.
• Knowledge of ICD_10, coding, billing practices.
• Knowledge of Family Care Services policy and procedures and ability to coordinate care requirements with patient centered goals in mind.
• Knowledge and ability to independently plan, manage, and organize work in order to meet priorities, accomplish work within established time frames and work in stressful situations.
• Knowledge of the occupational functions of multi-disciplinary integrated health care teams.
• Knowledge of the culture and health profile of the patient population.
• Knowledge and ability to teach and counsel patient/family and staff on plans for care and use of health care resources/services.
• Knowledge of available health care programs and community resources available to the member including tribal, county, regional and state services.
• Knowledge of processes and procedures for establishing, revising, continually monitoring, and evaluating standards of HOP.
• Knowledge of NCCare360 platform and the function thereof.
• Knowledge of medical record documentation and how to perform medical record reviews.
• Ability to communicate to and interact with persons, (staff, health care professionals, individuals in the community) with different functions, levels of knowledge, and requirements.
• Knowledge of JCAHO accreditation standards, social services quality improvement standards, HCFA regulations, Medicare, Medicaid, and private insurance.
• Ability to gather and analyze data and communicate findings.

Complexity of Duties 

Guidelines consist of professional standards of practice, medical policies and procedures. Must comply with Compliance Plan, Utilization Review Plan, State and Federal guidelines, CMS, FPM, DHHS, PHS, and IHS regulations. These guidelines are not always specifically applicable to the individual patient or situation and independent judgment is required in selecting the most appropriate guideline, and applying the intent.

Requirements are complex in that they require comprehensive skills in Social Services and Case Management and have sufficient knowledge of medicine to evaluate patient care. This may involve difficult interactions with the clinical staff, case managers, care managers and insurance payers and require maximum skills in diplomacy and judgement.

Supervision Received

HOP Medical Social Worker receives administrative guidance from the HOP Program Director, HOP Supervisor and clinical guidance from the TO Care Management DON. Works within the framework of regulations, policies, and procedures established by the agency, CMS, and North Carolina Division of Medical Assistance. Further guidance is received from Professional Literature, Indian Health Service Manuals, and Program Area Directives. Is expected to exercise a high degree of independent initiative and judgment in development and implementing new approaches to the delivery of quality care. Functions with a minimum of guidance and supervision. The HOP Program Director sets the overall objectives and resources available.

Responsibility for Accuracy

The HOP Medical Social Worker’s performance affects the health, recovery, and rehabilitation of patients, and the quality of care provided. Evaluations and observations are used to modify and develop clinically and financially appropriate treatment plans. The incumbent has a positive effect upon the recovery of the patient and is responsible for the development of policies and procedures, which serve as hospital guidelines.

Contact with others

Contacts are with patients of all ages, families, hospital personnel, community agencies, and insurance carriers. Contacts with patients, families, and hospital personnel are to exchange, provide, and obtain information concerning the patient’s physical and psychosocial health care problems and needs. Contacts with other health care or related disciplines and insurance carriers are for the purpose of coordination, collaboration, and consultation in meeting the patient’s health care needs.

Confidential Data

The Privacy Act of 1974 mandates that the incumbent shall maintain complete confidentiality of all administrative, medical, and all other pertinent information that comes to his/her attention or knowledge. The Act carries both civil and criminal penalties for unlawful disclosure of records. Violations of such confidentiality shall be cause for adverse action.

Mental/Visual/Physical Environment

Work in various services within the nursing department requires moderate amount of walking, standing, and bending. Pushing and lifting are required in moving equipment and other supplies. The ability to cope with the volume of patients, contacting various agencies in coordination of services, and coping with constant changes is required. Some mental stress may be associated with decision-making.

Work Environment

Provides activities from an office setting as well as providing monitoring activities in hospital area moderate risks

of exposure to infectious disease, radiation, and electrical hazards.

Customer Service

Consistently demonstrates superior customer service skills to patients/customers by demonstrating characteristics that align with CIHA’s guiding principles and core values. Ensure excellent customer service is provided to all patients/customers by seeking out opportunities to be of service.