Department: Community Care Team
Position is located: 797 Wilson Street
Work Type: Full Time
Work Schedule:8:00 AM to 5:00 PM- REMOTE OPPORTUNITY!!
Works under the supervision of the designated Community Care Team Lead.
Serves in an expanded role to collaborate with patients, Primary Care Providers, practice teams, all community agencies, including, but not limited to, behavioral health, housing authorities, Department of Health and Human Services, transportation and home health organizations, and other medical/specialty services to provide a model of care that ensures the delivery of quality, efficient, and cost-effective healthcare services. Assesses patient needs from a strengths based, person in environment manner, to design and implement coordinated intervention plans that monitor and evaluate options and services that aid towards meeting the shared goal of optimizing the patient's physical and bio-psycho-social-spiritual health status and lowering avoidable costs associated with less than optimal health and/or misuse/overuse of medical/community based services.
The Social Worker works collaboratively within Beacon Health's care coordination program and all care team members to ensure patient needs are met and care delivery is coordinated, and not duplicated, across the healthcare continuum. The expertise of the Social Worker is sought to assess and intervene with bio-psycho-social-spiritual barriers to patient's engaging with the healthcare system in a manner that promotes optimal health. Utilizes shared decision making models, collaboration, motivational interviewing, and other evidence based patient engagement, activation, and care coordination interventions to encourage positive behavior change in orderto assist patients to achieve their highest level of function.
*2. Assists to develop coordinated care plans for patients with complex medical and/or behavioral health needs. Fosters a team approach by working collaboratively with all practice and community based team members, including but not limited to formal and informal supports such as: family members, neighbors, primary care providers and other members of the health care team, and community based supports to ensure coordination of services.
*3. Assist to identify outreach, wellness and education planning needs of the identified members and communicate findings to the Care Coordinator or CCT Lead.
*4. Coordinates referrals between and among physical and behavioral providers to necessary and appropriate community resources to assist patients to meet their goals and improve functioning. Ensures appropriate clinical information is shared timely with peers, providers and outside agencies while adhering to system privacy standards.
*5. Provide outreach, including telephonic, meetings or oral presentations, to community based and county transportation (or designated subcontractors) to assist members to access services.
*6. Works closely with payers to appropriately apply member benefits and serve as a resource to the member and healthcare team.
*7. Adheres to EMHS' and Beacon Health's policies regarding member confidentiality.
*8. Maintains required documentation for all patient care activities. Collects required information and utilizes it to perform care coordination and collaborate with all team members to enhance patient care.
*9. Works with Beacon Health leadership to continuously evaluate process, identify problems, and propose process improvement strategies to enhance the Community Care Team, Patient Centered Medical Home, and Health Home Programs.
*10. Incorporates excellent written, verbal, and listening communication skills, positive relationship building skills, and critical analysis skills into social work practice.
11. Performs social work activities, as set forth herein, in a variety of settings, including, but not limited to PCP offices, patient homes, hospital, or other community based settings as deemed appropriate for each individual high risk or complex patient in collaboration with Care Coordinator, contracted home health agency or primary care provider and all other service and health providers who the patient is working with.
12. Develop collaborative relationships with community based agencies to understand and disseminate program and service eligibility, thus allowing for efficient use of referral systems aimed at improving care.
13. Utilizes appropriate conflict resolution, assertiveness, advocacy, brokerage, negotiation, and collaboration skills in facilitating patients' movement throughout the health care continuum.
17. Performs duties as required or assigned by emergency or other operational reasons for which the employee is qualified to perform.
*Denotes essential job functions.
Demonstrates ability to work autonomously and be directly accountable for practice.
Demonstrates ability to influence and negotiate individual and group decision-making.
Demonstrates ability to function effectively in a fluid, dynamic, and rapidly changing environment.
Demonstrates leadership qualities including time management, verbal and written communication skills, listening skills, problem solving and decision-making, priority setting, work delegation and work organization.
Demonstrates organization and delegation, negotiation and conflict resolution, and possesses the ability to be self-directed, flexible, and committed to the team concept.
Demonstrates teamwork, initiative and willingness to learn, accepts and respects diversity without judgment, and demonstrates strong customer service values.
Knowledge of Social Work theories, therapies and intervention techniques as used in individual, family and group treatment.
Knowledge of the basic health and wellness concepts required.
Critical thinking skills required. General computer knowledge and capability to use computers required.
Employee is exposed to environmental factors such as dust, fumes, temperature, humidity, heights, machinery, driving.
MAJOR DUTIES AND RESPONSIBILITIES:
*1. Works with Beacon Health leadership in the design, implementation, and evaluation of Community Care Team services within the larger Care Coordination, Patient Centered Medical Home and Health Home Programs.
14. Acts as a care partner to Care Coordination, Patient Centered Medical Homes and Health Home programs to assist practice members to appropriate referral sources.
15. Participates in all required training and supervision to maintain State of Maine Social Work licensure.
16. Utilizes evidence based screening tools to gather information related to barriers, strengths, and symptoms, which impact patient function. Shares information with practice team in order to enhance and improve outcomes.
SKILLS AND EXPERIENCE:
Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.
Demonstrates the ability to receive stimuli from multiple sources simultaneously.
LICENSURE/CERTIFICATION: Current Maine license of LCSW or LMSW-CC
EDUCATION and TRAINING
Minimum of 2 years work experience in the area (s) of social work, counseling and rehab. .
Master's Degree in Social Work (MSW) from accredited Council of Social Work Education University.
Positions may require adult, geriatric, and/or pediatric specific experience. However, experience across the lifespan is preferred.
Must have a reliable vehicle and valid Maine driver license.
WORKING CONDITIONS/PHYSICAL DEMANDS:
Other duties or comments specific to this position: Expected to drive on a wide range of roads and in inclement weather.
The specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.
Equal Opportunity Employment
We are an equal opportunity, affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, age, disability status, gender, sexual orientation, ancestry, protected veteran status, national origin, genetic information or any other legally protected status