Social Worker

Community Social Worker

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 Community Social Worker overall goal is to help people who have chronic, life threatening or altering diseases and disorders to connect with plans and resources to help them maintain an optimum level of health. The incumbent advocates for services and resources for the underprivileged and victims of abuse, neglect or other difficult family situations. Additional duties and responsibilities include working closely with the nurse case managers to transition patients to the appropriate level of care post hospital/SNF discharge and may perform post discharge follow up in the home. The social worker will adhere to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance, and policies and procedures. Supervision is received from a Director who evaluates quality of results through personal conferences and analysis of records and activity reports.

Essential Job Duties/Responsibilities:

• Assists with the management and plan for transitions of care, discharge and post discharge follow up for HPP patients
• Assess the patients for psychosocial, financial, family issues, palliative care/end of life issues, home safety, etc. that contributed to the hospitalization and/or could contribute to future hospitalizations.
• Assess patients for Medicaid criteria and assist with application process as needed.
• Assessments will be conducted in the center office, by phone call or patient's home. Could occur in hospital/SNF as needed,
• Collaborates with clinical staff in the development and execution of the plan of care and achievement of goals.
• Supports the integration of social services/case management functions in the pre-acute, ER, acute and post-acute setting.
• Coordinates with the case manager, patient and family, support the patient transition to the appropriate/least constrictive level of care assuring needed resources are in place.
• Introduces self to patient/family and explain community social worker role and procedure to contact for needed resources.
• Coordinates obtaining community resources/services that the patient needs and qualifies for as appropriate, e.g., Medicaid, meals, medications, housing, daycare, DME, HHA. etc. If skilled needs or needs for DME are identified, discuss with PCP and make referrals to preferred providers.
• Provides high intensity engagement with patient and family.
• Facilitates patient/family conferences as needed to review goals of treatment, patient personal goals of care, and life planning.
• Enhances a collaborative relationship to maximize the patient's/family's ability to make informed decisions.
• Participates in Super Huddles as appropriate.
• Maintains clinical and progress notes for each patient receiving care and provide progress report to PCP and others as appropriate.
• Submits required documentation in a timely manner and in appropriate computer system.
• Provides social services to patients, families, and significant others to enable them to deal with the impact of illness on individual family functioning and to achieve maximum benefits from healthcare services.
• Serves as a patient advocate.
• Other duties as assigned and modified at manager's discretion.

Knowledge, Skills and Abilities:

• Knowledge of case management theory and practice.
• 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 and older adulthood.
• Knowledge of advance care planning and palliative care, and related skill in addressing with patients and/or their family systems.
• Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.
• Critical thinking skills required.
• Skill in communication with and psychosocial support of patients with cognitive impairment.
• Skill in psychosocial interventions with challenged caregivers/family systems of high-risk patients.
• Skills in organizing and coordinating.
• Ability to work autonomously is required.
• Ability to monitor, assess and record patients' progress and make adjustments accordingly.
• Ability to communicate technical information to non-technical personnel

Education and Experience Criteria:

• Bachelor's degree in Social Work is required (BSW) from accredited university. Master's Degree in Social Work is preferred.
• Minimum of 2 years of social work, case management, and/or discharge planning experience is preferred.
• Hospital, healthcare setting experience is preferred.
• Strong interpersonal, communication and critical thinking skills are required.
• Ability to work autonomously is required.
• Minimum two (2) years of clinical experience.
• Minimum of one (1) years of case management, home health, and/or discharge planning experience is preferred.
• Certified Case Manager certification is preferred.

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.