With guidance from the Market Director of Population Health Management, works collaboratively with physicians, staff and other healthcare professionals within his/her clinically integrated network (CIN), Arkansas Health Network, to provide care coordination across the healthcare continuum for patients. The social worker is an integral member of the healthcare team who works to ensure patients are able to navigate through the healthcare continuum while improving the coordination of care and patient/family experience. Coordinates a wide range of community-based and healthcare support services for patients. The goal is to better manage patients in the ambulatory setting by providing a variety of support functions which contribute to the overall improvement in patients’ healthcare quality of life as well as efficient use of resources.
HIPAA SECURITY COMPLIANCE:
Security Access: High “Incumbent has access to restricted or confidential patient information
and must comply with the terms of the CIN and delivery system Security Policies as it applies to
their job role.”
1. Uses social work expertise to provide care management across the continuum for identified highest risk (complex) patients.
a. Proactively acts as a patient’s advocate, responding to and working to resolve concerns
b. Provides health promotion activities and education for patients
c. Optimizes patient and family independence through providing education and links to community resources
d. Works with families and patients on needs that may or will affect the patient’s health, including transportation issues, financial concerns, end of life planning, etc.
e. Identifies potential barriers related to patient’s home setting and self-care/management needs and works with patient (and caregiver) to resolve issues
f. Maintains an active case load of “at risk” patients using identification and stratification tools, direct referrals from the patient’s healthcare team (physician, RN Population Health Coach, etc.) and other knowledge
2. Actively participates in quality activities:
a. Assessing and collaborating with clinic managers and directors for CIN practices on strategies to achieve individual clinic level goals such as quality and efficiency
b. Communicating and coordinating with health care team in the development of tools for optimal patient outcomes and report findings
c. Meets on a regular basis with other outpatient population health team, as coordinated by CIN Leadership, for information sharing and continuing education activities
3. Accountability for results:
a. Understands and self-manages to support CIN-level success goals, including improvements in quality, cost of care and member experience for CIN’s population
b. Identifies opportunities for improvement (at individual, clinic and CIN levels) and actively works with healthcare and CIN team to correct or improve results
a. Exhibits behavior in alignment with CHI St. Vincent “Values In Action”
b. Exhibits behavior and adopts practices to ensure optimal risk management and financial stability
i. Identifies potential risk management or clinical quality issues and resolves them through intervention or collaboration with other members of the healthcare team as appropriate or refers the issue to the appropriate individual(s)
ii. Observes Universal Precautions consistently. Wears proper Personal Protective Equipment when appropriate.
iii. Maintains knowledge of and adheres to current CHI St. Vincent facility and AHN Department policy and procedures.
c. Demonstrates ethical behaviors and provides confidentiality in all interactions
i. Identifies and reports ethical situations to AHN Leadership and Ethics Committee for resolution.
ii. Respects patients/guest/coworkers personal property
iii. Maintains confidentiality regarding personnel and strategic plans
iv. Maintain confidential AHN interaction with vendors, third party payers and patient/family at all times
v. Adheres to CHI St. Vincent HIPPA policy and procedures
5. Advocacy for quality outcomes:
a. Acts as a patient advocate for optimum care and a business partner to the physician
b. Participates as a team member to facilitate communication among all disciplines, identify barriers to meeting treatment goals, and determine ways to achieve best outcomes
c. Provides information and support to patients and families, helping them access needed resources within the medical center and community
d. Assists physicians in obtaining needed services for their patients and having access to all available data on best practice and financial outcomes
e. Cultivates collegial partnerships with physicians and other healthcare professionals and maintains high customer satisfaction ratings in dealing with patients and their significant others
f. Demonstrates innovative problem-solving skills and ability to analyze and organize data to provide evidence for necessary process changes
6. Communicates effectively:
a. Resolves situations as appropriate within scope of job. Handles complaints/concerns in a prompt and courteous manner; assess and directs to appropriate person to deal with concerns as needed; makes attempt to solve issues with involved parties.
b. Demonstrates tact, courtesy, sound judgment and a professional attitude when relating with patients, families, coworkers, physicians and affiliated agencies.
c. Gives and receives feedback in a positive manner.
d. Communicates both verbally and in writing with physician and appropriate hospital staff regarding patient needs and progress of discharge plan.
e. Meets with AHN Leadership to discuss case specific issues.
f. Actively participates in staff meetings for information exchange, discussion of performance indicator results and action planning.
g. Develops professional relationships with community partners.
7. Professional public image:
a. Portrays a positive public image at all times.
b. Acts as a role model for others.
c. Recognizes, appreciates, accepts and values differences in people and treats all with dignity and respect.
d. Attends and participates in CHI St. Vincent facility committees as assigned.
e. Wears clothing and CHI St. Vincent identification badge consistent with dress code and attends to personal hygiene to maintain a clean, well-groomed appearance.
f. Maintains attractive, safe and clean workspace.
g. Meets CHI St. Vincent facility attendance standards.
8. Team work:
a. Builds and maintains positive relationships with the healthcare team- placing organizational/team goals first.
b. Assumes responsibility, authority and accountability for patient load, assisting other coworkers when requested or as the need arises.
c. Meets deadlines and takes responsibility for accomplishing one’s own work.
d. Takes feedback from coworkers and uses feedback to improve performance.
e. Participates in peer evaluations.
f. Identifies and actively participates in projects to assist with team self-actualization.
g. Participates as a team member with department wide events/programs.
h. Uses appropriate resources and methods to resolve conflicts with others in a positive and professional manner.
a. Documents accurately in the population health management IT platform.
b. Uses technology for risk management, quality improvement activities, data collection, process improvement and evaluation of improvement interventions.
c. Maintains technical knowledge and skills of computer systems (Cerner, Star, eClinicalWorks, Epic, population health IT platform and email)
10. Organization skills:
a. Consistently makes appropriate mandatory reports to appropriate agencies.
11. Other duties as assigned
MINIMUM KNOWLEDGE, SKILLS AND ABILITIES REQUIRED:
Education: Bachelor of Social Work (BSW) degree required.
Licensure/Certification: A current unencumbered SW license to practice in the State of Arkansas is required. Certification in case management (CCM) preferred, public health and/or community health preferred.
Experience: Three years of social work experience in a healthcare setting. Experience working with Medicare and Medicaid populations and related social/economic issues preferred. Experience in patient education preferred.
Skills: Must have strong organizational (time management) skills, strong interpersonal skills
and the ability to handle multiple priorities. Knowledge of and practical use of good business English, spelling, arithmetic, practices and the ability to communicate effectively using written and verbal skills. Proficient in email communications and internet usage along with basic use of Microsoft Excel and Word. Knowledge of information technology to evaluate care effectiveness (care process, outcomes and cost). Basic Life Support (BLS) for the Healthcare Provider certified or obtained by the end of the orientation period (approximately six (6) weeks). Proof of completion of Mandatory Reporter abuse training specific to population served within three (3) months of hire. Ability to work autonomously within matrix environment without direct supervision or support.
Requisition ID: 2018-R0147508