Social Worker, Community Health

Social Worker – Oregon Health & Science University

Join to apply for the Social Worker role at Oregon Health & Science University

This range is provided by Oregon Health & Science University. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.

$86,367.32/yr - $/yr

OHSU Health Services is committed to the ongoing journey of being an anti‑racist organization that acknowledges the enduring impacts of historical injustices on health; addresses clinical, social, and structural systems and conditions that undermine health and wellness; strives to become a culturally‑proficient workplace that reflects the communities served; and fosters an environment of belonging, respect, and inclusion where everyone feels empowered and safe to bring their full, authentic selves to the work.

Change requires individuals at all levels of the organization to be proactive in redistributing resources and power equitably by restructuring policies, clinical and financial strategies, culturally sensitive data analysis and the way data is used. OHSU Health unequivocally expects its staff and leadership to fully support this mission in these efforts.

The Integrated Community Care Manager Social Worker (ICCM‑SW) is an integral member of the multi‑disciplinary Care Integration and Coordination Program. The ICCM‑SW provides on‑site (face‑to‑face) and telephonic outreach, behavioral health, disease and/or care management, care coordination, education, support and navigation to OHSU Health Services Members with the goal of supporting healthy life choices and to reduce long term effects of chronic illness.

The individual in this role performs other clinically based activities to assist in the coordination of care between the member, his/her provider(s), health care facilities, and community‑based health organizations. The ICCM‑SW offers social work intervention and coordination of needed services to Members and/or families experiencing psychosocial adjustment difficulties associated with illness, injury, disability and related hospitalization and/or health care interventions. The ICCM‑SW enhances the quality of Member management by promoting continuity of care and cost effectiveness through whole‑person care management, care integration, and care coordination across the continuum of health care services.

• Provides on‑site (face‑to‑face) and telephonic outreach, disease management and/or care management, education and other clinically‑based activities for OHSU Health Services Members. Provides supportive counseling to reinforce Members’ strengths and assists them in dealing with the stress and feelings of grief, fear, and anger associated with serious illness, injury, hospitalization or disability.
• Conducts interviews and assessments with Members and/or Member families and other community resources to gather information necessary in identifying and evaluating psychosocial, cultural and financial conditions, develops plans of care and interventions, and sets goals for plans of care and behavioral modification within his/her scope of practice.
• Collaborates with OHSU Health Member’s medical and health community‑based providers (that may include the primary care provider (PCP), specialist provider, behavioral specialists, or others as may be indicated) regarding the member’s treatment and resource needs and plan of care. The frequency of contact is determined based on the member’s risk acuity ranking and clinical need.
• Collects clinical and engagement data and enters information into the electronic medical record (EMR) for tracking and metric purposes. Routinely documents all Member interactions and member engagements in the EMR to ensure a longitudinal record is maintained of all member interactions. Maintains medical record confidentiality at all times through the proper use of computer passwords, maintenance of secure files; adherence to HIPAA guidelines and policies.
• Monitors, evaluates and maintains knowledge of community‑based resources and services necessary to respond to…