Central Ohio Primary Care Physicians is seeking a Social Worker to join our Care Coordination team in Westerville, OH. The Social Worker works closely with Physicians, Nurse Care Managers, Pharmacists, and other care team members to provide and develop plan of care. Responsibilities include assessing and managing transition plans for patients who are at high risk for readmission for social, psychological and/or environmental needs related to the impact of admission, diagnosis, treatment, and discharge. This position receives referrals from across the network of Physicians, working closely with transition of care Nurses and Nurse Care Coordinators to identify high-risk patients who are appropriate for disease or care management programs. The Care Coordinator, Social Worker is responsible for identifying and understanding community-based resources and connecting patients with these resources as needed. 25-40% of the role requires face to face visits with patients in homes and office settings as needed. This position if full-time working Monday- Friday, 8a-5p and will primarily cover central Ohio and contiguous counties.
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:
Complete patient assessments to evaluate all social, psychological, or environmental needs related to the impact of admission, diagnosis, treatment, or discharge.
Provide patient/caregiver with education, information, and referral Provide patient/caregiver with relevant information about medical illness, behavioral health, insurance coverage, support, and community services.
Develop plan of care for patients in collaboration with the primary care team. Document in the medical record as indicated and designated case management tool accurately.
Perform Face-to-Faces as necessary including home, office and skilled rehab facility settings . Evaluate possible barriers to attainment of self-management goals and develop strategies to
Provide ongoing communication between the patient and health care team to ensure improved patient outcomes and high quality of patient care.
Facilitate referrals to other disciplines and internal health and community based programs as needed to improve patient outcomes.
Participate in departmental process improvement initiatives, work on special projects as needed and attend all departmental meetings.
Serve as an advocate and resource for the patient/caregiver.
Provide temporary case management to a specified case
QUALIFICATIONS:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
