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Social Services Coordinator
2 months ago
ChenMed is seeking a highly skilled and compassionate Social Worker to join our team. As a Social Worker, you will play a critical role in providing psychosocial assessments, social case work, and linkage to community resources for patients with chronic, life-threatening, or altering diseases and disorders.
Key Responsibilities- Needs Identification and Assessment:
- Conduct timely and appropriate assessments and needs identification, prioritizing patients on the Primary Care Physician's High Priority Patients (HPP) and Top 40 patient lists.
- Assess patients for psychosocial, financial, family issues, palliative care/end of life issues, home safety, etc. that negatively impact their health outcomes.
- Medicaid and Other Benefit Eligibility Assessments:
- Conduct appropriate assessments of needs and financial benefit eligibility.
- Assess patients for Medicaid criteria and assist with application processes as needed.
- Assist patients to obtain community resources/services as appropriate, e.g., meals, medications, housing, daycare, Home Health Aide, and other Social Determinants of Health (SDoH) needs as identified.
- Resource Coordination and Prevention:
- Serve as a care coordinator linking patients with internal and external resources, prioritizing high-risk patients with the greatest needs.
- Facilitate connections to community resources as identified by the patients' SDoH Wellness Screening.
- Work with patients, family, and interdisciplinary care teams to facilitate applications for higher levels of care.
- Maintain an accurate repository of social wellness tools and resources for the care team's awareness and utilization with patients in need.
- Communication:
- Maintain communication with interdisciplinary team members by attending appropriate meetings (i.e., weekly Super Huddles and Hospital and Community Care Team (HCT) meetings).
- Provide consultation in an integrated healthcare environment regarding social determinants of health and community resources.
- Timely and Accurate Documentation:
- Maintain timely, accurate, thorough, and appropriate documentation/reports per company policies and procedures.
- Initial psychosocial assessments will be completed within 48 hours.
- All follow-up visits, phone calls, and collaborative contacts will be documented within 24 hours.
- Assure documentation meets billing guidelines.
- Education: Bachelor's degree in Social Work required; Master's degree in Social Work (MSW) preferred.
- Experience: A minimum of 2 years' work experience in social work, case management, and/or discharge planning required; a minimum of 2 years' experience in a primary care setting preferred.
- Licensure: State licensure at a Master's level is preferred but may be required (dependent on state).
