Facilitates the management of illness, striving to achieve measured advancements in the patient's health status.
1. Manages and coordinates interdisciplinary care of defined populations through the care continuum from wellness through end of life from a psychological, social and environmental perspective. 2. Identifies high risk patients requiring on-going coordination of care; performs a comprehensive patient/family assessment, develops a comprehensive treatment plan that will span the continuum of psychosocial issues, implements a plan of care to provide continuing support and coordination for patient/family with multiple complex system needs, manages benefits and negotiates continuing care services for enrollees in various health insurance plans, etc. 3. Utilizes innovative strategies to advocate for patient needs and negotiates complex systems to remove barriers and limitations in accessing health care in regards to psychological, social and environmental areas. 4. Monitors the patient’s transition across and within care settings (e.g., home, clinic, skilled nursing facility, rehabilitation, hospital, etc.). 5. Shares assessment and psychological, social and environmental care plan data with patient/family consent as the patient moves through different care settings. 6. Identifies gaps in the care continuum and work with the community and provider networks to expand access to needed psychological, social and environmental services. 7. Participates in the development of disease management strategies and identifies the appropriate measures for the evaluation of outcomes. 8. Participates in the development, maintenance, and coordination of an interdisciplinary care delivery system specific to individual patient needs and promotes effective resource utilization. 9. Collects and evaluates data/outcomes, including, but not limited to, patient satisfaction, health and functional status, and resource utilization. 10. Performs other duties as required or assigned.
ü Master’s Degree in Social Work (MSW) with 5 years of clinical experience required.
ü Critical thinking skills, strong leadership and communication abilities, the ability to be a self-starter, negotiate, and handle conflict resolution desired.
ü Understanding of and comfort using computers desired.
ü Collaborative team player, use of systems approach in planning, problem solving and decision making, creativity, innovation, risk taking, autonomy, flexibility, receptiveness to change and a commitment to professional growth desired.