Community Social Worker
Company: ChenMed
Location: Warren
Posted on: November 18, 2023
Job Description:
We're unique. You should be, too. We're changing lives every
day. For both our patients and our team members. Are you innovative
and entrepreneurial minded? Is your work ethic and ambition off the
charts? Do you inspire others with your kindness and joy? We're
different than most primary care providers. We're rapidly expanding
and we need great people to join our team. 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. He/She advocates 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. 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.Communication.
- 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. KNOWLEDGE, SKILLS AND ABILITIES:
- Keen business acuity and acumen
- Full knowledge and understanding of general Social Worker
functions, practices, processes, procedures and techniques
- Knowledge of social services documentation procedures and
standards
- Knowledge of community health services and social services
support agencies and networks
- Knowledge of normative changes (e.g., sensory, cognitive,
psychosocial) associated with aging for high-risk patients
- Knowledge of advance care planning and palliative care, and
related skill in addressing advance care planning
- Ethical practice behavior consistent with ChenMed policies and
professional standard
- Skill in psychosocial interventions with challenged
caregivers/family systems of high-risk patients
- Appropriate utilization of community-based resources
- Teamwork skills in care coordination with patients, family
systems, staff, and external providers
- Ability to work autonomously is required
- Ability to monitor, assess and record patients' progress and
adjust accordingly
- Ability to communicate technical information to non-technical
personnel, and with patients and/or their family systems
- Strong interpersonal, communication and critical thinking
skills and the ability to work effectively with a wide range of
constituencies in a diverse community
- Demonstrated ability to provide care effectively and
sensitively to people from different cultural groups
- Ability to create a collaborative relationship to maximize the
patient's/family's ability to make informed decisions
- Proficiency in written communication: documentation is clear,
concise, accurate, provides meaningful communication and is
consistent with company policy and regulatory requirements
- Proficiency in technology, including the utilization of
Electronic Medical Record platforms for care coordination
- Proficient in Microsoft Office Suite products including Word,
Excel, PowerPoint and Outlook, plus a variety of other
word-processing, spreadsheet, database, e-mail and presentation
software
- Ability and willingness to travel locally, regionally and
nationwide up to 30% of the time
- Spoken and written fluency in English
- This job requires use and exercise of independent judgment
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
- State Licensure at a Master's Level is preferred but may be
required (dependent on state)
- If applicable, 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 We're ChenMed and we're transforming
healthcare for seniors and changing America's healthcare for the
better. Family-owned and physician-led, our unique approach allows
us to improve the health and well-being of the populations we
serve. We're growing rapidly as we seek to rescue more and more
seniors from inadequate health care. ChenMed is changing lives for
the people we serve and the people we hire. With great
compensation, comprehensive benefits, career development and
advancement opportunities and so much more, our employees enjoy
great work-life balance and opportunities to grow. Join our team
who make a difference in people's lives every single day.
Keywords: ChenMed, Warren , Community Social Worker, Healthcare , Warren, Michigan
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