Geriatric Care Social Worker

10 hours ago

Rochester, New York, United States Wellbe Senior Medical Full time
Job Title: Geriatric Care Social Worker

Wellbe Senior Medical is seeking a compassionate and skilled Geriatric Care Social Worker to join our team. As a Geriatric Care Social Worker, you will play a vital role in providing high-quality care to our elderly patients and their families.

Job Summary:

The Geriatric Care Social Worker will be responsible for coordinating traditional social work referrals and community outreach to address the needs of patients with social and behavioral problems and social determinants of health issues. You will work closely with our physicians, advanced practice providers, and behavioral health specialists to deliver quality care.

Key Responsibilities:
  • Telephonic outreach to patients and providers requesting assistance with community resources and social determinant of health needs.
  • Develop plan of care responding to patient requests and assessment outcomes.
  • Provide community resource coordination for patient requests and psychosocial problems.
  • Collaborate efforts with multidisciplinary team to identify and respond to patient psychosocial needs.
  • Develop and organize Wellbe community resource directory.
  • Utilize internally approved computer systems to identify internal and external resources.
  • Document assessment and patient encounters following Wellbe standards and best practices.
  • Builds rapport with patients and their families and relay all concerns to Wellbe provider/IDT
  • Coordinates with other healthcare providers, agencies and community resources in order to create a thorough treatment plan addressing social, cultural, and financial needs
  • Collaborates with the interdisciplinary team and participate in regularly scheduled team meetings
  • Ensures compliance with regulatory agencies and Wellbe clinical guidelines
  • Partner with community team to refer patients to appropriate no or low-cost community services that support health and independence such as Meals On Wheels (MOW), local Area Agencies on Aging (AAA), Senior & Assistance Programs, and transportation resources.
  • Involves the patients' families and primary caregiver(s) as needed to achieve the best care decisions and outcomes.
  • Effectively collaborates with all those involved in the members' care, including health services contractors (i.e., Home Health, Hospice, Community Agencies), to meet the patients' care goals.
  • Complies with safety policies and procedures, identifying and immediately reporting any potential or actual unsafe acts or conditions to their supervisor/team. Takes necessary measures to ensure a safe environment for oneself, co-workers, contractors, participants, visitors and others.
  • Consistently meets or exceeds Wellbe targets for productivity, customer service, quality assessment, and performance targets.
  • Understands the importance of community involvement and participates as appropriate in activities that link Wellbe to its communities.
  • Maintains current written progress notes and other documentation on the member Medical Record including signed and dated documentation for all service performed the day the service is provided.
  • Participates in program and policy development of the Wellbe Social Work program.
  • Other tasks needed to accomplish team's objectives/goals
Requirements:
  • Master's Degree in Social Work
  • Two years social work experience, preferably in health care and case management, and minimum one-year experience working with a frail/elderly population.

Wellbe Senior Medical offers a supportive work environment focused on compassionate patient-centered care, innovation, and collaboration. If you are passionate about providing high-quality care to our elderly patients and their families, we encourage you to apply for this exciting opportunity.

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