Job Description

Position Purpose:

The role of the Social Worker, General is to assist individuals, families, and internal teams who are impacted by Social Determinants of Health (SDOH) needs. The objective of the Social Worker is to assist the individual and/or family to access services and provide available resources within Steward Health Care Network (SHCN) and the community.

Essential Duties and Primary Responsibilities:

  • Provides telephonic care coordination services to high risk patients that are impacted by Social Determinants of Health such as: food insecurity, financial resources, legal assistance, transportation, applying for disability, accessing services, application assistance, etc.
  • Provides advocacy, patient education and support in accessing community-based and hospital-based programs.
  • Utilizes resources of public and private agencies and community organizations to meet the needs of patients and families.
  • Assists patients with organizing their records, making follow-up appointments, and filling their prescriptions.
  • Helps patients fill out applications, for example for Medical Assistance and SNAP (Supplemental Nutrition Assistance Program)
  • Makes referrals to case managers, as appropriate, and/or refers patient’s family to community support services and resources.
  • Schedules and completes initial assessment, develops a patient-centric plan of care and schedules follow-up within specified timeframes
  • Initiates telephonic or face to face contact with high risk patients of all ages to conduct a Care Needs Screening
  • Evaluate Care Needs Screening responses and make appropriate referrals to internal care management programs or to external resources.
  • Records and monitors the participants’ progress toward goals within specific timeframes
  • Collaborate with youth and family service agencies at the local, county and state level including but not limited to schools, special education services, DCFS, family court systems.
  • Works collaboratively with the members PCP and/or other key providers in planning and directing each patient’s treatment program
  • Clearly documents all activities in the patient record
  • Provides concise and thorough documentation through psycho/social assessment and progress notes, including changes in medical psycho/social functioning, progression and attainment of goals, referrals to internal and external agencies, and contact/involvement with patient’s family.
  • Demonstrates cultural sensitivity and respect for the patient

Education:

  • Bachelor’s Degree in Social Work, Psychology, Counseling, Rehabilitation or other related field, required
  • Master’s degree preferred
  • BLS Certified (CPR/First Aid)

Work Related Experience:

  • Experience working with the needs of vulnerable populations who have chronic or complex psychosocial needs
  • Experience working with disadvantaged populations, preferred
  • Experience in a managed care environment and case management experience, preferred
  • Must be able to effectively communicate, present and explain complex material with patients, family members, case managers, treating physicians and community organizations
  • Must possess the interpersonal skills to engage children and adolescents of varying ages and families in helping relationships.
  • Must be able to cope with the pressure of time limitations while respecting the needs of the patient and the requirements of the organization/department.
  • Ability to take action in solving problems while exhibiting sound judgment and a realistic understanding of issues; able to use reason, even when dealing with emotionally charged topics.
  • Ability to remain open-minded and change opinions on the basis of information, perform a wide variety of tasks and change focus quickly as demands change, and manage transitions effectively from task to task.
  • Exceptional organizational skills; ability to multi-task and work independently and part of a team
  • Demonstrate ability to prioritize, multitask, and work in a rapidly changing environment with multiple demands
  • Working knowledge of government and community based resources and delivery systems needed to assist patients to address homelessness/housing instability/Social Determinants of Health.
  • Experience providing resource information and continued support to patients to ensure access to services to address homelessness/housing instability/Social Determinants of Health utilizing culturally sensitive practices.

Mental and Physical Demands:

  • Must be able to effectively communicate with internal and external customers via telephone and email.
  • Able to accurately receive information through oral communication.
  • Able to accurately review data and figures both in hard copy and electronic formats.
  • Utilize a computer (including but not limited to a mouse and keyboard) and telephone intermittently throughout entire shift, for periods of up to four (4) hours at a time.
  • Able to accurately sort through data and think through issues in a time-pressured environment.
  • Able to focus on a specific event or activity for up to four (4) hours at a time without interruption.
  • Able to maintain a calm and collected presence while addressing the concerns from an internal and external customer
  • Able to accurately learn and retain new information, knowledge and skills.
  • Able to efficiently manage multiple tasks, with varying degrees of priority, at the same time.

    Application Instructions

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