Job Description

Position Summary:

Population Health (PH) Concierge care Coordination (C3), Social Worker facilitates the psychosocial care of patients to ensure quality outcomes and appropriate utilization of health care resources. Is a key member of a multi-disciplinary team whose primary objective is to provide care coordination services to high-risk enrollees through evaluation of psychosocial and economic co-morbidities. Participates in identification activities (panel management), bio/psycho/social assessments, patient education, behavior change counseling, and other related activities for all lines of business, including managed care contract programs which includes elders and adults with disabilities who require LTSS. Assists with providing linkages to community resources and care plan goal achievement. Performs all job duties and responsibilities in a courteous, customer-focused and ethical manner.

Essential Duties and Responsibilities:

1. Provide Psychosocial Support: Demonstrates the ability to provide psychosocial support and linkages to community resources for assigned patients, addressing their unique needs and barriers to care.
2. Care Plan Development and Monitoring : Participates in the development and ongoing monitoring of individualized care plans with the multi-disciplinary healthcare team, patients, and family/caregivers. Focuses on promoting patient strengths, advancing patient well-being, and assisting patients in achieving their health goals.
3. Assessment and Ongoing Evaluation: Conducts comprehensive assessments of patients' psychosocial functioning and needs, including evaluation of chronic illness impacts, social determinants, support systems, coping abilities, and prior functioning levels. Assesses patients' progress and adjusts the care plan as necessary throughout enrollment in the population health management program.
4. Standardized Post-Discharge Assessments :

Conduct comprehensive, standardized post-discharge assessments to ensure patients experience a safe and seamless transition of care, from inpatient care to their home or community setting, as well as to identify ongoing support needs, and comply with quality performance measures. This assessment aim to:

• Evaluate Patient Stability: Assess the patient's physical, emotional, and psychosocial well-being post-discharge to identify any immediate risks or concerns.
• Identify Ongoing Support Needs: Determine the necessity for additional medical, behavioral health, or social support services, such as home health, transportation, medication management, or follow-up appointments.
• Ensure Medication Adherence and Understanding: Verify that patients understand their prescribed medications, including dosage, potential side effects, and the importance of adherence to prevent readmission.
• Assess Social Determinants of Health (SDOH): Identify barriers such as food insecurity, housing instability, or lack of caregiver support that may impact recovery and long-term health outcomes.
• Enhance Care Coordination: Facilitate communication between healthcare providers, case managers, and community organizations to align post-discharge care with the patient's needs and preferences.
• Monitor Readmission Risk: Use evidence-based screening tools to evaluate the risk of hospital readmission and implement necessary interventions to reduce avoidable readmissions.
• Improve Patient Education and Self-Management: Provide tailored guidance on managing chronic conditions, recognizing warning signs, and accessing available resources to promote patient independence.
• Ensure Compliance with Quality Performance Measures: Adhere to contractual and regulatory requirements by documenting assessment findings, follow-up actions, and patient outcomes in accordance with quality and accreditation standards.
• Facilitate Family and Caregiver Engagement: Engage family members or caregivers in the discharge planning process to ensure they have the necessary knowledge and resources to support the patient’s recovery.
• Track and Report Outcomes: Collect and analyze post-discharge data to assess program effectiveness, identify gaps in care, and contribute to continuous quality improvement efforts.

5. Resource Mobilization and Intervention

6. Consultation and Coordination

7. Family Engagement and Support

8. Medical Co-Management

9. Care Coordination and Barrier Reduction

10. Interdisciplinary Collaboration

12. Resource Coordination

13. Community Resource Familiarity

14. Patient Education

15. Collaboration and Emotional Support

16. Regulatory Knowledge

17. Performance Improvement Participation

18. Professional Documentation

19. Judgment and Critical Thinking

20. Quality Monitoring

21. Patient Advocacy

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

Skills and Abilities:

List specific knowledge and skills necessary to perform this job related to the Essential Duties and Responsibilities identified above. Specific physical and/or cognitive requirements that are essential parts of the job.

• Must be self-motivated
• Possess the ability to communicate effectively
• Excellent human relations skills
• Be able to work effectively in a team setting
• Ability to follow a project or assignment through a successful completion.
• Ability to read and interpret documents such as general business periodicals, professional journals, procedure manuals and/or governmental regulations.
• Ability to write routine reports and correspondence.
• Ability to speak effectively before groups of customers or employees of organization.
• Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.
• Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

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 this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic, travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity and inclusion.

Qualifications

• Minimum of a master’s degree in Social Work (MSW) with a Licensed Clinical Social Worker (LCSW) credential

Certificates & Licenses:

• State Licensure - Must meet the state-specific licensure requirements for social workers
• LCSW Licensure in State of Florida required
• Certified Case Manager (CCM®) preferred
• Certification in Population Health or Health Coaching (Preferred)

Experience:

• Social Work Experience: minimum of 3-5 years related field
• Experience in Managed Care/Health Plan Setting : 3-5 years of experience in a managed care, health plan, or insurance setting.
• Experience with Utilization Management and Care Coordination : Experience coordinating care across medical, behavioral, and social service providers, including familiarity with utilization management processes, appeals, and authorizations.
• Knowledge of Medicaid/Medicare Regulations : Experience working with Medicaid, Medicare, or other state and federal health care programs, including knowledge of relevant regulations and compliance requirements.
• Knowledge of Microsoft Office and internet software
• Knowledge of EPIC and/or JIVA (preferred)

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