Support Service Coordinator

The Social Worker plays a vital role as part of the care team within our organization. This role serves as a patient advocate, empowering patients to actively participate in their healthcare decisions and treatment plans by fostering self-awareness, self-advocacy, and coping skills to effectively manage their health conditions and navigate the healthcare system.

• Assessment and Screening:
  Conducting advance care planning and cognitive assessments to identify patients' needs, strengths, and challenges. This may include screening for mental health conditions, substance abuse issues, domestic violence, and other social determinants of health.
• Crisis Intervention:
  Offering immediate support and intervention for patients experiencing acute mental health crises, including suicidal ideation, self-harm, or emotional distress.
• Coordination with Care Team:
  Collaborate closely with care team members to coordinate comprehensive care plans that address both medical and psychosocial needs.
• Resource Referral:
  Facilitating connections between patients and community resources, such as support groups, mental health services, financial assistance programs, transportation services, and home health care agencies, to enhance patients' overall well-being and quality of life.
• Advocacy:
  Serving as an advocate for patients to ensure their needs are addressed within the healthcare system and community settings. This may involve assisting with access to social services, disability benefits, housing assistance, or legal support.
• Family Support:
  Providing guidance, education, and counseling to patients' families and caregivers to help them navigate the challenges of caring for a loved one with complex medical and psychosocial needs.
• Documentation:
  Maintaining accurate and confidential documentation of assessments, treatment plans, progress notes, and communication with patients and other healthcare professionals in accordance with legal and ethical standards.
• Cultural Competence:
  Recognizing and respecting the cultural, ethnic, and socioeconomic diversity of patients and tailoring interventions and treatment approaches to meet their unique needs and preferences.
• Chronic Care Management:
  Provide continued education and strive to enroll eligible patients into the CCM program. Appropriately and accurately document and log CCM activities and work in partnership with the care team to keep the patients CCM care plans up to date.
• Communication with Care Team:
  Facilitate communication and coordinate among the patient’s care team members to ensure a comprehensive and integrated care delivery. Communicate with providers and staff via phone, email, Teams, Athena, or in-person.
• Patient Communication:
  Interact with patients via email, patient portal, telephone, text, in-person, etc. to gather necessary information, schedule and confirm appointments, and provide pre-appointment instructions. Respond to patient inquiries, resolve scheduling conflicts, and assist in rescheduling appointments when necessary.
• Staff Communication:
  Foster effective communication between the care team to facilitate coordinated team-based care.
• Customer Service:
  Provide exceptional customer service to patients, exhibiting a compassionate and empathetic attitude. Address patient concerns, inquiries, and complaints professionally and promptly, striving to meet patient needs and ensure their satisfaction.
• Administrative Functions:
  Perform general administrative tasks and support other staff as needed. Work assigned buckets, ticklers, census lists, and region’s scheduling voicemail tasks. Utilize the company’s software systems to enhance patient care and staff productivity.
• Collaboration and Coordination:
  Collaborate with internal and external resources to facilitate and ensure seamless operations.
• Must be available during normal work hours (unless previously approved by direct supervisor). Additional hours may be required to complete normal business functions and/or projects.
• Utilize the company’s software systems and update information as required.
• Participate in coaching calls.
• Perform other duties as requested or required, in the sole discretion of the…