The Social Worker provides behavioral health outreach, identifies social determinants of health, and facilitates linkages to community resources. They collaborate with a clinical care team to develop and implement comprehensive care plans for members.
Position Summary: The Social Worker is a behavioral health professional providing outreach to members. They assist in identifying social determinants of health, barriers to care, providing a linkage to appropriate community resources, and facilitating referral to other services through collaboration. This role works with our Clinical Care Team which includes RN’s, ARNPs, RDs and WCs in order to provide our members with comprehensive quality outcomes.
Responsibilities:
Complete appropriate Behavioral Health Assessments to collect information to identify psychosocial needs, social determinants of health, and/ or barriers to care using established assessments and relay this information to the Clinical Care Team for care planning
Assist in telephonic outreach for purposes of engagement of KHM eligible members
Accountable for individual metrics as defined by the leadership
Provide actionable interventions and supportive counseling to members and families which could include assistance with housing, finances, utilities, transportation, and mental health barriers
Facilitate linkage to appropriate community health/human services and assist with locating wrap-around services available in the community
Encourage adherence to provider treatment plan and Clinical Care Team Plan of Care
Collaborate with outside agencies to ensure continuity of care
Participate and provide updates in team meetings, 1:1 meetings with leadership, and attend in-service training
Document in HealthMap’s Care Management Systems as appropriate
Perform other related duties as requested
Requirements:
Master’s degree in social work is required
An active, unrestricted, state board-issued LCSW (Licensed Clinical Social Worker) license is highly preferred
3 years of experience in healthcare or human services agency setting
Experience in a managed care setting
Experience working in the community with knowledge of renal health and/or community resources preferred
Skills:
Strong interpersonal skills are required to motivate patients and others
Excellent written and verbal communication
Cultural awareness and knowledge
Ability to independently identify problems, clarify facts, and organize information to identify trends, information gaps, or need for additional information
Must be proficient in Microsoft Office: Outlook, Word, Excel, PowerPoint
Travel:
Limited Travel, Scheduled per needs of the business
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