Social Worker - Full Time - Days

Full Time

Monday - Friday 8am to 4pm

Lebanon, PA  location

Master's Degree preferred

Job Description:

Collaborates with all members of the care team including the primary care practice to plan and implement optimal and efficient care plans for medically and psychosocially complex patients under population health value based care risk arrangements. This includes direct provision and/or assistance in the provision of psychosocial and overall mental health services for designated patients and their families in the primary care setting.Employs a range of time limited, focused, clinical interventions such as individual, group or family counseling. Provides caregiver/family counseling and/or support to promote family cohesiveness to provide care to the patient and prepare families for end of life. Advocates on behalf of patients and families to gain access to services and resources. Refers patients to other providers as necessary.This position requires a broad-based knowledge of mental health conditions, psychosocial issues and chronic diseases which impact health. Utilizes evidenced based practice and national standards to optimize the mental health of the high-risk medical and psychiatric population and to maintain these patients in the community, avoiding hospitalization when appropriate through timely behavioral help follow up and intervention.

Duties and Responsibilities

1. Utilize Motivational Interviewing techniques as a patient-centered approach to activate patients in self-management related to social determinants of health.
2. Maintain a caseload of patients according to department policies.
3. Meet patients in their home, primary care office, and other locations as identified.
4. Assess social determinants of health and behavioral health needs of patient population.
5. Activities include but are not limited to: Connect patients to community resources, helps with counseling (billing), immigration/citizenship, self-help/actualization skills, placement of patients to SNF, ECF, Personal Care from their home environment, and education/health system navigation.
6. Develop and implement care plans to maximize healthcare outcomes and facilitate wellness with periodic review and update according to department protocols.
7. Perform medication review and teach-back to ensure patient understanding and ability to adhere to medical regimen.
8. Collaborate with Care Managers, PCPs, Specialists, and Hospitalists to effectively implement a patient-centered care plan.
9. Perform patient outreach according to established protocols and document in electronic medical record.
10. Identify, execute, and track needed referrals to care and community resources
11. Provide resource management to improve care, patient experience and reduce unnecessary cost and utilization: right care, right place, right time.
12. Assist patient in advanced care planning to complete Advanced Directives.
13. Documents patients’ assessments, care plans, goals and interventions in electronic medical management system according to NCQA standards.

Qualifications:

• Minimum Experience:
  • 3 years in Healthcare.
  • Pref Field of Expertise
  • Social Work
• Minimum Education:
  • Bachelor’s Degree
• Preferred Education:
  • Master’s Degree
• Required Certification:
  • Basic Life Support (BLS) certification.