Social Worker- Support Services Coordinator

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General Description

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.

General Description

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.

AREAS OF RESPONSIBILITY

A successful Social Worker will be able to perform these essential duties and responsibilities. Reasonable accommodations may be made, in accordance with applicable law, to enable individuals with disabilities to perform the essential functions.

The following is a list of essential functions, which may be subject to change at any time and without notice. Management may assign new duties, reassign existing duties, and/or eliminate function(s).

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 approve to health 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…