JOB SUMMARY
Assists patients and their families in coordinating medical, social, emotional, insurance, and vocational issues related to injury or illness. Conducts psychosocial assessments, either in -person or telephonically, in order to develop a comprehensive out-patient care plan that guides work with patient. Collaborates with physicians, nurses, support staff, community agencies, and other health care professionals to implement safe, effective, and timely patient care. Communicates with treating clinicians on areas of concerns and provides clinical updates to clinicians on a regular basis. Provides timely and appropriate documentation in patient's electronic medical record. Participates in assuring that the client is in the forefront of applying Case Management principles. Participates in achieving the goal of cost effective, high quality, continuous care to patients; communicates effectively with clinicians, patients, and team leader to achieve this goal. Utilizes team leader as appropriate for clinical consultation and to apprise of legal, ethical, risk issues that may affect the patient, family, or health services. Maintains quality assurance and improvement activities in compliance with client standards. Assists in development of reports and resources required by other departments.

DUTIES AND RESPONSIBILITIES
Assumes responsibilities of an active caseload, including following patients throughout the continuum of care.
Provides Ambulatory Case Management services to identified patients through a process of research, patient interview, development of care plans and monitoring of care.
Researches clinical history of identified patients using all necessary and appropriate resources.
Provides a clinical assessment either telephonically or as appropriate in person to assess patient’s needs and perception of their health status.
Provides pre-operative outreach and assessment to identified student athletes.
Assists patients and their families coordinate medical, social, emotional, insurance, and vocational issues related to injury or illness.
Educates patients and families regarding Advance Directives and assists patients and families in completing Advance Directives.
Promotes effective communication with hospitals and their departments. Educates them to resources available at the Client Health Services.
Participates in/attends IM Team Meetings and daily huddles.
Participates in/attends client committees/work groups when appropriate.
Communicates with primary care clinician, patient, and home care provider to ensure medically necessary services. Regularly communicates with patients requiring post- discharge service to assess patient satisfaction and that appropriate services are in place.
Evaluates utilization and effectiveness of Home Care provider network .
Assess quality of care of Home Care providers as well as responsiveness. Addresses areas of concerns with manager to ensure optimal quality of care for patients.
Educates patients/families about non-skilled services for patients when necessary. Assists in arranging for these services when patients/families allow.
Acts as a liaison between patients and the client to assist in coordinating follow up services.
Ensures the department maintains effective communication with other Client Departments.
Educates client staff about Care Coordination’s scope of service and how to utilize client case managers as resources.
Identifies areas of improvement; recommends and implements solutions.
Actively participates in project development. Collaborates with manager to implement, evaluate, and support programs to maximize utilization of available resources.
Assists in maintaining a Quick Reference Resource Guide.
Educates patients/families/caregivers as to trajectory of certain disease processes and level of support/care needed throughout disease pro cess.
Educates patients/families about health insurance processes and when appropriate benefits. Directs patients/families where to learn more about health insurance benefits.
Provides supportive counseling to patients and families to enhance coping skills and resolve concerns.
Provides supportive counseling to patients and families considering changes in living situations or managing changes related to a medical condition. Collaborates when appropriate with BCBS MA Nurse Case Manager in case management of patients with complex medical and psychosocial needs.
Develops a comprehensive treatment plan. Monitors and assesses appropriateness of treatment plan and makes appropriate modifications as necessary.
Communicates with PCP or treating clinician on areas of concern in addition to ongoing updates on clinical progress.
Reports incidences of suspected abuse and neglect of children, elders, and individuals with disabilities to appropriate designated state agency.
Organizes and participates in patient case conferences as needed Provides timely, appropriate, comprehensive clinical documentation in patient's electronic medical record.
Provides cross coverage for co-workers as needed.
Attends department staff meetings.
Is punctual and prepared for duties at start of shift.
Is reliable and dependable in coming to work.
Gives appropriate notice to manager when unexpected circumstances call for staff member to be away from work.
Utilizes time productively.
Participates in the orientation of new staff members.
Identifies own learning needs and requests assistance from others when needed.
Works independently, as well as collaboratively, with all members of the health care team.
Treats patients with dignity, respect, and compassion.
Provides prompt care/service and behaves sensitively in all interactions.
Deals with others in a sensitive, tactful, positive, and courteous manner.
Accepts and acts upon feedback.
Utilizes team leader as appropriate for clinical consultation and to apprise of legal, ethical, risk issues that may affect the patient, family, or health services.

QUALIFICATIONS/REQUIREMENTS

Required
Masters in social work. Current license to practice social work in MA, either LCSW or LICSW. Minimum of 2 years of social work experience in medical setting. Familiar with managed care and case management principles.

Preferred
Ability to work independently and as part of a team. Familiar with care needs of medically complex young adult, adult, and geriatric populations. Ability to provide a high level of customer service to patients, staff, and external customers in a professional, service-oriented, respectful manner in using skills in active listening and problem solving. Excellent organizational, analytical, problem solving and interpersonal skills.

Required Experience:
Provides ambulatory case management services to identified patients through a process of research, patient interview, monitoring of care utilization patterns and development of care plans.
Collaborates with clinical staff to provide a comprehensive outpatient care plan. Communicates with treating clinicians regarding areas of concern and provides regular clinical updates.
Participates in assuring that UHS is at the forefront of applying Case Management principles.
Educates medical staff on criteria/guidelines as appropriate.
Works with the team leader to identify areas of concern in clinicians' practice patterns and assists in developing resolutions.
Identifies potential quality of care issues.
Assists in development of reports and resources required by other departments.
Excellent organizational, analytical, problem-solving, and interpersonal skills.

Required:
Minimum of three years social work experience in a medical setting.
Familiar with managed care and case management principles.
Familiar with care needs of medically complex children, adults, and geriatric populations.

Required Licensure:
MA LICSW or LCSW (no LMHCs, LSWs etc)

HIGHLY preferred Hospital Social Worker familiar with discharge planning, heavy telephone communication, charting, case management: home care, new diagnosis.

Need someone who can jump in with minimal training.

This is a small team that manages approximately 40-50 cases each, hospitalizations, and completes advance directive outreach.

Notes:
Fully Onsite
Time: 40 hours/ week with 1/2 hour unpaid lunch
Schedule: Monday – Friday: 8:30am – 5pm OR 8am – 4:30pm