Job Title
Primary Functions:
- Responsible for patient outreach, assessment, disease management, and care coordination to patients with high rates of medical and behavioral health utilization and/or psychosocial vulnerability
- Assess patients through telephonic and eventually face to face encounters
- Builds a collaborative relationship with patients and their identified support system to encourage care participation and improve self-management of needs
- Utilizes motivational interviewing to identify barriers and facilitate care plan compliance
- Effectively educates patients about healthcare delivery, plan benefits and a variety of topics related to health, and community resources
- Coordinates timely and appropriate implementation of assessments, care plans, and interventions for the identified patient population
- Provides medication reconciliation and support ongoing adherence
- Provides transitional care management
- Identifies and helps to align patient care and community resources to prevent hospital readmissions and Emergency Department visits
- Documents all activity in the documentation systems relevant to the role
- Collaborates with the care team to achieve high-quality, low-cost outcomes for patients
- Interfaces and maintains positive relationships with key providers in the local hospitals, community practices, and organizations to ensure proper patient engagement and follow up
- Achieve established productivity targets
- Maintains compliance with the organization policies and procedures
- Demonstrates the ability to adapt, innovate and lead in a fast-paced environment, where change is common
- Passionate about making a difference in individual's lives
- Other duties as assigned
Qualifications:
- Requires a Master's in Social Work
- Must have a current full licensure as a LCSW by the NC Social work Certification and Licensure Board
- Two years post master's clinical experience is required
- Medical Social Work experience strongly preferred
- Knowledge of care management and quality principles are preferred
- Requires the ability to maintain confidentiality
- Must be able to interact with individuals of all cultures and level of authority
Additional skills required:
- Excellent and effective written and oral communication skills
- Proficiency in Microsoft Office Outlook, Word, Excel, PowerPoint use and e‐mail communication
- Ability to communicate clearly and succinctly
- Dependable, manages time well; efficient and organized
- Requires the ability to maintain confidentiality
Benefits:
- 401(k)
- Health, Dental and Vision insurance
- Employee assistance program
- AFLAC
- Paid time off