Job Purpose: 1. Works in partnership with clinic staff to identify, engage and support patients presenting with a range of health related issues. 2. Provides care management services and case specific problem-solving to enable patients to access health care and community based supports which improve health status and quality of life. 3. Supports women with issues related to women's health: gynecological issues, pregnancy, infertility, adjustment to parenthood, pregnancy loss, etc... 4. Evaluates patients for mental health/substance abuse problems and psychosocial factors impacting care. Refers patients accordingly. 5. Collaborates with payers, caregivers, staff and patient care team members to provide systemically informed care and health management for identified patients 6. Links and collaborates with staff at primary care service sites and other specialty care, to foster a meaningful and collaborative approach to health management and care integration. 7. Demonstrates a capacity to participate in a collaborative multi-disciplinary team process, with an ability to establish a meeting agenda and support the team through the care planning process. 8. Engages patients and family members to assist in assessment and care planning 11. Identifies and effectively utilizes community based services to support patient's needs (i.e.– Cancer Support groups, ASAPS, AA/NA, hospice, Bereavement support, etc...). 12. Collaboration will require participation in caregiver conferences, patient at-risk meetings, and other meetings as needed. 13. Collaborates with mental health providers to support medical management for patients with co-morbid mental health and substance abuse disorders.
Education/Training: Masters degree in Social Work or an equivalent degree in a related field.
Licensure: Current MA licensure as LICSW (Licensed Independent Clinical Social Worker) or eligibility for licensure. LCSW (Licensed Clinical Social Worker) is adequate when pursuing required supervisory hours in order to be eligible to register for LICSW exam.
Certifications: Same as above. CCP/CCM or equivalent certification preferred. Palliative Care, End-of-Life or Hospice certification, a plus Work Experience: Previous experience in healthcare and case management preferred.
Physical Skills: Typical office setting. Will include home and community based visits and coordination with ambulatory and inpatient locations. Telephonic as well as face-to-face sessions, family meetings and team conferences.
Mental Skills: Clinical, organizational and systemic skills. Capacity to support patients with multiple psychosocial challenges and serious medical illness.
Basic computer skills, including Microsoft Word, Excel and Powerpoint and capacity to learn EMR documentation. Other software training provided. Bi-lingual skills a plus