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Master of Social Work, Care Coordinator
4 months ago
Arizona Community Physicians, P.C.
Master of Social Work - Care Coordinator
Job Summary
Works under the direction of the ACO Medical Director and RN Care Coordination Manager in the area of Care Management and Population Health. A prime area of focus will be case management of higher risk patients. Other areas of focus may include transitional care management, population health management, quality improvement, staff education, engagement and patient support through various Care Management Programs.
As a team member with Abacus Health, we serve through our mission and purpose of the Triple Aim + 2:
1. Improving the patient experience of care (quality and satisfaction)
2. Improving the health of populations
3. Reducing the per capita cost of health care
+2 Includes improving physician and employee satisfaction and Abacus income
Minimum Qualifications
Education: Completion of an accredited MSW program.
Work Experience: Minimum of two years of experience in case management, preferably in a medical setting.
Preferred Experience/Qualifications: Prior experience in case management, population health management, utilization management and quality programs. CCM credential is desirable.
Other Qualifications: Excellent written and verbal communication skills. Proficient with MS Word, Excel and Outlook.
Responsibilities
Clinical: Work with the ACP Medical Director to improve clinical outcomes and help reduce total medical costs. Assist in ACO-directed quality improvement efforts foster innovation as ACO continues to evolve new patient care programs.
Care Coordination – Interact daily with clinical offices affiliated with Abacus Health to provide care coordination for patients needing short-term care coordination.
Case Management – Supports high-risk patients with the purpose of helping them be more effective at managing their own care. Empower patients to understand their medical conditions and medications, navigate the healthcare system and utilize resources appropriately. Provide education and emotional support to these patients and develop trusting relationships with them. Meet their paneled patients face-to-face at least once in their physician’s office or other healthcare facility or the patient’s home. Create a patient centered plan with each patient and consistently document all interactions with each patient. Communicate significant clinical information regarding these patients to other members of the healthcare team and especially to the patient’s PCP.
Short term Care Management - One -time or limited outreach assistance with care coordination.
Act as a liaison between community resources helpful to patients (e.g., volunteer agencies, assistance programs) and educate assigned ACP staff about community resources that can help them in office management of high-risk patients. Use advocacy, communication and resource management, while promoting quality and cost-effective interventions and outcomes. Facilitate the achievement of patient wellness and autonomy through advocacy, assessment, planning, communication, education, resource management, and service facilitation. Maintain appropriate documentation to track quality improvement and cost reduction activity
Customer Service: Promotes excellence in patient relations and customer service, emphasizing compassion, responsiveness, respect and courtesy. Uses active listening skills, gathering information to enhance patient care and improve patient health outcomes.
Teamwork: Works harmoniously with others, demonstrating a commitment to achieving common goals. Communicates in a manner that promotes trust and mutual respect. Maintains a professional demeanor in dealing with conflict and difficult issues. Adapts to changes in job duties and workplace with a positive and cooperative demeanor.
The intent of this job description is to provide a summary of the major duties and responsibilities performed by individuals in the job title. Individuals may be required to perform additional job-related tasks as needed.
