Location: Fort Lauderdale,FL, USA
Position Summary:
Population Health Social Worker facilitates the psychosocial care of patients to ensure quality outcomes and appropriate utilization of health care resources. Is a key member of a multi-disciplinary team whose primary objective is to provide care coordination services to high-risk enrollees through evaluation of psychosocial and economic co-morbidities. Participates in identification activities (panel management), bio/psycho/social assessments, patient education, behavior change counseling, and other related activities for all lines of business, including managed care contract programs which includes elders and adults with disabilities who require LTSS. Assists with providing linkages to community resources and care plan goal achievement. Performs all job duties and responsibilities in a courteous, customer-focused and ethical manner.
Essential Duties and Responsibilities:
* Demonstrates the ability to provide linkages and psycho-social support for assigned patients.
* Participates in the development and monitoring of an individualized plan of care with the multi-disciplinary health care team, patient and family/caregivers that promote patient strengths, advance patient well-being, and assist patients achieve their goals.
* Assesses patient's progress and participates in plan of care throughout enrollment in population health management program.
* Mobilizes resources, intervenes as necessary and evaluates actions to achieve expected goal.
* Provides consultation to Population Health Care Managers when coordination with significant or intensive community resources is necessary to achieve desired treatment outcomes.
* Identifies the need for and conducts family meetings that result in informed decisions and other outcomes.
* Refers to and confers with appropriate medical professionals for co-management of patients with complex medical and social needs.
* Formulates and implements appropriate plans of care reducing barriers to care, which result in preventing hospital admissions and/or emergency room visits.
* Actively participates in interdisciplinary Population Health staff meetings.
* Documents findings in the enrollee database including the patient's or families' involvement and knowledge of the plan and care needs of the enrollee.
* Coordinates with other disciplines to determine, arrange, or provide the most beneficial program, therapy or activity to contribute toward the patient's ability to self-manage their health, based on the age population and psychosocial needs of the patients.
* Demonstrates ability to maintain a familiarity of community resources.
* Maintains current community resources directory current.
* Educates patients and families of the requirements and limitation of local and federal programs as they pertain to the patient's needs.
* Demonstrates ability to collaboratively coordinate care with other disciplines to provide appropriate psychosocial and emotional support for patients.
* Maintains and includes in practice updated general knowledge of managed care regulations, Medicaid/Social Security guidelines and community agency programs and limitation.
* Participates with continuous performance improvement reviews and reports as assigned.
* Demonstrates ability documenting and updating all referrals and counseling sessions.
* Conducts a comprehensive assessment of patient and family/caregiver's psychosocial functioning and needs as they relate to chronic illness including prior functioning levels, appropriateness, social determinants, adequacy of support systems, reaction to illness and ability to cope.
* Utilizes professional judgment, critical thinking, and self-management techniques to assist patients in overcoming barriers to goal achievement.
* Identifies and refers potential quality concerns per corporate policy.
* Collaborate with population health team to monitor practice/process improvements for effectiveness of workflow, service provision, and risk reduction.
This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.
Skills and Abilities:
[List specific knowledge and skills necessary to perform this job related to the Essential Duties and Responsibilities identified above. Specific physical and/or cognitive requirements that are essential parts of the job.]
* Must be self-motivated
* Possess the ability to communicate effectively
* Excellent human relations skills
* Be able to work effectively in a team setting
* Ability to follow a project or assignment through a successful completion.
* Ability to read and interpret documents such as general business periodicals, professional journals, procedure manuals and/or governmental regulations.
* Ability to write routine reports and correspondence.
* Ability to speak effectively before groups of customers or employees of organization.
* Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.
* Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
Work Schedule:
As a continued effort to provide a safe and productive work environment, Community Care Plan is currently following a hybrid work schedule. Staff are able to work from home 3 days a week and will report to the office 2 days a week. *The company reserves the right to change the work schedules based on the company needs.
Physical Demands:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds.
Work Environment:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic, travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.
We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity and inclusion.
Qualifications
* Minimum of a master's degree in Social Work with a minimum of 3-5 years related field.
* LCSW Licensure in State of Florida preferred.
* Certified Case Manager (CCM) preferred.
* Knowledge of Microsoft Word, Microsoft Outlook, Microsoft Excel, and internet software.