Medical Social Worker

§  Work in conjunction with nurse navigator on intake assessment including social needs/barrier identification of patients referred and enrolled in the program; determine plan for care with nurse navigator; responsible for management and completion of social/behavioral tasks for each individual patient

o   Tasks may include, but are not limited to:

§  Education geared toward self-reliance and independence

§  Interventions aimed at reducing barriers to medical care

§  Coordinate behavioral health services

§  Assist pt in making appointments as necessary and accompany patients to appointments as needed

§  Referrals to community resource services

·       Engage patients across care settings such as the transition from hospital to home

·       Assist patients and their families with personal and environmental difficulties which predispose them toward illness or interfere with achieving maximum level of functioning and self-sufficiency

·       Act as a liaison between hospitals, primary care providers, specialists, community resources and managed care/insurance plans on behalf of enrolled patients to ensure patient-centered coordination of care

·       Serves as a patient advocate and assists in the identification and improvement of service delivery.

·       Provide crisis intervention as needed

·       Provide direct supervision to the community health coach

·       Develop and maintain partnerships with local service organizations and community resources to broaden support services for patients

·       Provide Notary Public services to patient/family members in order to complete Advance Directives.

·      Enter and maintain electronic records, compile reports and complete other program documentation in a timely manner , other administrative responsibilities as needed

·       Participate in interdisciplinary case conferences, staff meetings and team meetings

·       Play a consistent and active role in program development and growth

·       Meet on a regular basis with clinical supervisor to review case workload.

Must have available phone to communicate and transportation, with appropriate licensure and insurance, to visit homes and other sites.  Interacts with physicians, nurses, social workers and other disciplines, administrative personnel, and community resources.