Social Worker, Community Care Team

Northern Light Health
Job Description
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 order to assist patients to achieve their highest level of function.
  • 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 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 the ability to receive stimuli from multiple sources simultaneously.
  • 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.
  • 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.
  • Knowledge of Social Work theories, therapies and intervention techniques as used in individual, family and group treatment.
  • Positions may require adult, geriatric, and/or pediatric specific experience. However, experience across the lifespan is preferred.
  • Knowledge of the basic health and wellness concepts required.
  • Critical thinking skills required. General computer knowledge and capability to use computers required.
  • Must have a reliable vehicle and valid Maine driver license.
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