Social Worker
Job Description
Serves in an expanded role to collaborate with patients, Primary Care Providers, practice teams, and all community agencies, 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 the 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 evidence based shared decision making models, motivational interviewing, and other evidence based interventions to encourage positive behavior change in order to assist patients to achieve their highest level of function.
Responsibilities:
Responsibilities:
- Conduct assessments 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 patient assigned.
- 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.
- 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.
- Works closely with payers to appropriately apply member benefits and serve as a resource to the member and healthcare team.
- Maintains required documentation for all patient care activities. Collects required information and utilizes it to adjust the treatment plan when indicated.
- Adheres to policies regarding member confidentiality.
- Incorporates excellent written, verbal, and listening communication skills, positive relationship building skills, and critical analysis skills into social work practice.
- 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.
- Utilizes appropriate conflict resolution, assertiveness, advocacy, brokerage, negotiation, and collaboration skills in facilitating patient's movement throughout the health care continuum.
- Participates in all required training and supervision to maintain State of Maine Social Work licensure.
- Other Duties.
- Required Licensed Social Worker
- Required Bachelor's Degree
- Need to drive to perform responsible duties.
- Work with computers, typing, reading or writing.
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