Overview
The Social Worker plays a vital role as part of the care team within our organization. This role serves as a patient advocate, empowering patients to actively participate in their healthcare decisions and treatment plans by fostering self-awareness, self-advocacy, and coping skills to effectively manage their health conditions and navigate the healthcare system.
Responsibilities
- Assessment and Screening: Conduct advance care planning and cognitive assessments to identify patients' needs, strengths, and challenges. This may include screening for mental health conditions, substance abuse issues, domestic violence, and other social determinants of health.
- Crisis Intervention: Offer immediate support and intervention for patients experiencing acute mental health crises, including suicidal ideation, self-harm, or emotional distress.
- Coordination with Care Team: Collaborate closely with care team members to coordinate comprehensive care plans that address both medical and psychosocial needs.
- Resource Referral: Facilitate connections between patients and community resources, such as support groups, mental health services, financial assistance programs, transportation services, and home health care agencies, to enhance patients' overall well-being and quality of life.
- Advocacy: Serve as an advocate for patients to ensure their needs are addressed within the healthcare system and community settings. This may involve assisting with access to social services, disability benefits, housing assistance, or legal support.
- Family Support: Provide guidance, education, and counseling to patients' families and caregivers to help them navigate the challenges of caring for a loved one with complex medical and psychosocial needs.
- Documentation: Maintain accurate and confidential documentation of assessments, treatment plans, progress notes, and communication with patients and other healthcare professionals in accordance with legal and ethical standards.
- Cultural Competence: Recognize and respect the cultural, ethnic, and socioeconomic diversity of patients and tailor interventions and treatment approaches to meet their unique needs and preferences.
- Chronic Care Management: Provide continued education and strive to enroll eligible patients into the CCM program. Document CCM activities accurately and work with the care team to keep CCM care plans up to date.
- Communication with Care Team: Facilitate communication and coordinate among the patient’s care team members to ensure a comprehensive and integrated approach to health care delivery. Communicate with providers and staff via phone, email, Teams, Athena, or in-person.
- Patient Communication: Interact with patients via email, patient portal, telephone, text, in-person, etc. to gather information, schedule and confirm appointments, and provide pre-appointment instructions. Respond to patient inquiries, resolve scheduling conflicts, and assist in rescheduling appointments when necessary.
- Staff Communication: Foster effective communication between the care team to facilitate coordinated team-based care.
- Customer Service: Provide exceptional customer service to patients, exhibiting a compassionate and empathetic attitude. Address patient concerns professionally and promptly to meet patient needs and ensure satisfaction.
- Administrative Functions: Perform general administrative tasks and support other staff as needed. Use the company’s software systems to enhance patient care and staff productivity.
- Collaboration and Coordination: Collaborate with internal and external resources to facilitate and ensure seamless operations.
- Must be available during normal work hours (unless previously approved by direct supervisor). Additional hours may be required to complete normal business functions and/or projects.
- Utilize the company’s software systems and update information as required.
- Participate in coaching calls.
- Perform other duties as requested or required, in the sole discretion of the Company.
Mission and Expectations
Take responsibility for own work in completing tasks. Assist others so that resources, assistance, or support is provided to achieve success in daily work. Communicate, endorse, and demonstrate the Company’s mission, vision, and values. Prompt and regular attendance. Adhere to standards of behavior, dress code including name tag and approved uniform, personnel department, and company policies. Attend in-services and meetings on a regular basis. Promote a culture of outstanding customer service at all times. Must be available during normal work hours (unless previously approved by direct supervisor). Additional hours may be required to complete normal business functions and/or projects. Must possess the ability to deal tactfully with patients, employees, management, visitors, government agencies, and the general public and maintain an open-door policy for all employees. Must possess the ability to make independent decisions when circumstances warrant.
Work Environment
The Work Environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. May be exposed to cleaning agents and chemicals, humidity, hot equipment, and/or noise. May be exposed to infections, communicable diseases, odors, bloodborne pathogens, excreta, and hazardous materials.
Compliance
Comply with all federal, state, and local laws and regulations. Knowledge of Medicare guidelines, applicable laws and regulations, and the Company’s policy and procedures. Adhere to the Company’s Code of Conduct / Ethics. Must exercise a high degree of confidentiality regarding patients, personnel, and the company. HIPAA compliant. Promote a culture of compliance.
Physical Demands
- Must be able to lift, reach, bend, push, pull, use repetitive hand motions, walk, and carry simultaneously.
- Must be able to withstand reaching, stooping, bending, kneeling, and crouching; walking and standing for periods of time; lifting up to fifty (50) pounds.
- Must be in good general health and demonstrate emotional stability.
Qualifications
- High school diploma or equivalent required; an associate degree or bachelor’s degree in social work is preferred.
- A minimum of one year of experience in a healthcare setting is preferred.
- A minimum of one year of experience in social work is preferred.
- Must be proficient in utilizing technology tools and platforms for remote patient monitoring, telemedicine, and electronic medical records.
- Ability to read and communicate effectively.
- Strong written and verbal skills.
- Basic computer knowledge.
- Ability to manage and demonstrate effective leadership skills.
- Should demonstrate good interpersonal and communication skills under all conditions and circumstances.
- Ability to foster a cooperative work environment.
- Team player with ability to manage multiple responsibilities and demonstrate sound judgment.
- Must be able to work flexible hours and travel between offices, facilities, etc. Must be a licensed driver with an automobile that is insured in accordance with state and/or organizational requirements and is in good working order.