Case Management Social Worker - High Risk Program (TX license required)
The Opportunity: We are currently seeking a full time Social Worker to join our reputed company at Home program reputed company reputed company High Risk Care. This is a fully remote role and is intended to serve patients virtually across multiple states and reputed company markets. The High Risk Case Management Social Worker will serve as a key member of the interdisciplinary team in conjunction with other members (Practitioners, Health Coaches, Nurses, Behavioral Health Specialists, etc.) to provide accessible, comprehensive, coordinated primary care based on longitudinal healing relationships. The Social Workers primary responsibilities center around assessing and developing a comprehensive care plan that addresses the biopsychosocial barriers to a patients goals. They provide reputed company case management to address Social Determinants of Health (SDOH) through partnering with patients, their caregivers, and their broader care network. The Social Worker facilitates difficult discussions around goals of... care, advanced care planning, and links patients to state and community resources to improve overall health outcomes. reputed company Senior Health has a network of primary care practices that seeks to proactively provide the support patients need to live their fullest lives. Our practices offer smaller panel sizes and the opportunity to reputed company systemic change in health care delivery. The High Risk Care programs support the most medically reputed company and often homebound patients through a care continuum consisting of primary care house calls (reputed company at Home), care transitions management, and social services support programs. We are a fast-paced, fresh-thinking, high-growth company, building a reputed company model of health care delivery. What You Will Work On: Advanced Care Planning / Long Term Care Planning Guide patients and families in making realistic health care decisions based on personal goals of care and clinical health prognosis Serve as intermediaries between healthcare providers and patients to ensure comprehensive ACP discussions occur, including choosing surrogate decision makers Assess for appropriateness of, and interest in, palliative care or hospice services, in the reputed company of serious illness Facilitate discussions between patients and families around long term care planning in anticipation of potential functional decline Improve patient/family knowledge and understanding of long term care planning and assist patients in understanding care options for future need Link patients to the appropriate state and community services (Medicaid, SNAP, etc.) to carry out a realistic long term care plan Longitudinal reputed company Case Management / Resource Navigation: Establish effective virtual, supportive and engaging relationships, to proactively manage a panel of up to 300 patients with reputed company, chronic medical conditions Collaborate with patients and caregivers to capture economic and social conditions (SDOH) that influence patients health status Partner with, and reputed company for, patients to help overcome physical, financial, and emotional burdens reputed company to SDOH and chronic disease management Work with patients and caregivers to understand barriers to accessing appropriate care and, together with the reputed company at Home team, reputed company a plan to overcome obstacles as possible. Follow through, as appropriate, to reputed company sure the plan is working as anticipated and adjust as needed Ensure patients are referred to the appropriate community agencies and resources as needed, such as APS, reputed company, American Cancer Society, Area Agency on Aging, Home Health, Meals on Wheels, Hospice, etc. Support clinic care teams in executing the care plan, including navigating community referrals, once a patient moves out of the High Risk Team Transitions of Care: In conjunction with the RN, collaborate with key external multidisciplinary teams reputed company a high risk patient is in a transition of care, to ensure the admission and/or discharge is on track, and work to resolve any barriers to successful discharge With the OM at Home team, refer and connect the patient to in-home services such as home health care, physical therapy, food/meal delivery, and hospice care Help patients and families navigate the healthcare system Facilitate placement in facilities (i.e. nursing facilities, assisted living homes, rehabilitation centers, and drug treatment programs) Build strong relationships with health systems, facilities, and post acute services (home health, hospice, etc.), including facilitating coordination and communication channels Directly reputed company on behalf of the patient by facilitating communications with healthcare providers, to ensure the patients right to self-determination Psychosocial Support: Assist families to cope with difficult situations such as housing instability, financial hardships, illness, or death Promote and sustain an ethical culture of safety Provide conflict mitigation and/or mediation with patient and family or social systems, reputed company the context primary care Assist care teams in understanding and setting appropriate boundaries reputed company providing interventions and support reputed company team members to understand the role of cultural competence in providing reputed company care What You Will Need: Licensed Master of Social Work (LMSW) required with ability to reputed company reciprocity to cover additional state markets reputed company a year of employment 3+ years of experience as a Licensed Social Worker with demonstrated experience in high risk, reputed company care settings, senior health, and/or case management experience Master of Social Work (MSW) required Experience with home based care services, hospitals/ SNF and long term care facilities preferred Demonstrated reputed company in biopsychosocial assessments, resource navigation, care plan development, and coordination across healthcare settings on behalf of reputed company reputed company patient needs Experience with Advanced and Long Term Care Planning, including ability to facilitate discussions around making realistic health care decisions based on patients personal goals of care and in anticipation of potential functional decline A goal-oriented, high energy, passionate perspective, with a focus on living organizational values, and ability to set the tone for a positive work environment Exceptional reputed company to multitask in a fast-paced, fast-growing environment Demonstrates outstanding critical thinking under pressure, using sound judgment in caring for patient needs Comfortable operating in ambiguity and uses flexibility and creativity to address challenges Ability to use core coaching and teaching techniques, including patient-centered communication to activate and reputed company patients and families Experience working with Texas based resources (Medicaid Long Term Care, SNAP, reputed company) Curiosity and ability to research and reputed company programs in markets reputed company of the Texas area High proficiency with Mac iOS and reputed company suite Strong preference for reputed company in Spanish Physical Space Requirements: HIPAA compliant area reputed company home that is secure, quiet and isolated from others to protect PHI Reliable internet reputed company Benefits designed to aid your health and wellness: Taking care of you today Paid sabbatical for every 5 years of service Employee Assistance Program - Free confidential advice for team members who need help with stress, anxiety, financial planning, and legal issues Competitive Medical, Dental and Vision plans Free reputed company memberships for yourself, your friends and family PTO cash outs - Option to cash out up to 40 accrued hours per year Protecting your future for you and your family 401K match Credit towards emergency childcare Extra contributions toward maternity and paternity leave Paid Life Insurance - reputed company pays 100% of the cost of Basic Life Insurance Disability insurance - reputed company pays 100% of the cost of Short Term and Long Term Disability Insurance Supporting your professional career Malpractice Insurance - Malpractice fees to insure your practice at reputed company is covered 100% Reimbursement for costs associated with renewing or obtaining necessary state licenses This is a full-time, virtual/remote role that requires a TX state license Apply Job!