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 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.
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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 Company.
MISSION EXPECTATIONS

Take responsibility for own work in completing tasks. Assist others so that the resources, assistance, or support is provided to achieve success in their daily work.

Communicate, endorse, and demonstrate the Company’s mission, vision, and values.

Prompt and regular attendance.

Adhere to standards of behavior, dress code including name tag and approved uniform, personnel department, and company policies.

Attend in-services and meetings on a regular basis.

Promote a culture of outstanding customer service at all times.

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.

Must possess the ability to deal tactfully with patients, employees, management, visitors, government agencies, and the general public and maintain an open-door policy for all employees.

Must possess the ability to make independent decisions when circumstances warrant.
WORK ENVIRONMENT
The work environment characteristics described herein are representative of those an employee encounters while performing the essential functions of the job:

May be exposed to housekeeping cleaning agents and chemicals, humidity, hot equipment, and/or noise.

May be exposed to infections, communicable diseases, odors, bloodborne pathogens, excreta, and hazardous materials.
COMPLIANCE WITH POLICIES AND PROCEDURES

Comply with all federal, state, and local laws and regulations.

Knowledge of and compliance with Patient’s Bill of Rights.

Must be knowledgeable of Medicare guidelines, applicable laws and regulations, and the Company’s policy and procedures.

Adhere to the Company’s Code of Conduct / Ethics.

Must exercise a high degree of confidentiality regarding patients, personnel, and the company.

HIPAA compliant.

Promote a culture of compliance.
PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. Reasonable accommodations may be made, in accordance with applicable law, to enable individuals with disabilities to perform the essential functions.

Must be able to lift, reach, bend, push, pull, use repetitive hand motions, walk, and carry simultaneously.

Must be able to withstand reaching, stooping, bending, kneeling, and crouching; walking and standing for periods of time; lifting up to fifty (50) pounds.

Must be in good general health and demonstrate emotional stability.
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QUALIFICATIONS

High school diploma or equivalent required while an associate degree or bachelor’s degree in social work is preferred.

A minimum of one year of experience in a healthcare setting preferred.

A minimum of one year of experience in social work preferred.

Must be proficient in utilizing technology tools and platforms for remote patient monitoring, telemedicine, and electronic medical records.

Ability to read and communicate effectively.

Strong written and verbal skills.

Basic computer knowledge.

Ability to manage and demonstrate effective leadership skills.

Should demonstrate good interpersonal and communication skills under all conditions and circumstances.

Ability to foster a cooperative work environment.

Team player with ability to manage multiple responsibilities and demonstrate sound judgment.

Must be able to work flexible hours and travel between offices, facilities, etc. Must be a licensed driver with an automobile that is insured in accordance with state and/or organizational requirements and is in good working order.
I have received, reviewed, and understand the requirements of this job, and agree that I can perform the requirements of this position. I accept the position and agree to perform in accordance with established policies and procedures, and all Federal, State, and local laws, regulations, codes and accepted professional standards and principles that apply. I understand that if I require a reasonable accommodation to perform any essential function of my job, I will clearly communicate that to Human Resources. Every effort has been made to make your job description as complete as possible. However, it in no way states or implies that these are the only duties you are required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar or is a logical assignment of the position, in the sole discretion of the Company. This job description does not constitute a contract of guaranteed employment for any period of time. I understand that my employment is at-will and that I can be terminated at any time, with or without notice or cause.
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