The Social Worker provides outreach to members to identify social determinants of health and barriers to care while facilitating linkages to community resources. They collaborate with Care Navigators to develop care plans and provide supportive counseling to improve patient health outcomes.
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 Care Navigators who are RN’s to improve our member’s health care outcomes.
Responsibilities
Accountable for individual metrics as defined by the Care Services Director
Collect information to identify psychosocial needs, social determinants of health, and/ or barriers to care using established assessments and relay this information to the Care Navigator for care planning
Assist in telephonic outreach for purposes of engagement of members by client
Provide social work intervention 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
Complete appropriate Behavioral Health Assessments
Document in HealthMap’s Care Management Systems as appropriate
Encourage adherence to provider treatment plan and Care Navigator Plan of Care
Provide in-home evaluations for members who have engaged but are unable to reach as needed
Collaborate with outside agencies to ensure continuity of care
Participate in team meetings, 1:1 meetings with Supervisor, and attend in-service training
Provide Social Service updates at regular staff meetings
Perform other related duties as requested
Requirements
A MSW (Master’s degree in social work) is required
An active, unrestricted, state board-issued LCSW (Licensed Clinical Social Worker) license is 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
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