The Social Worker is responsible for addressing the clinical and non-clinical needs of members across the Population Health Management (PHM) continuum. The role focuses on supporting members with complex medical, behavioral, and social needs through person-centered care coordination, advocacy, and connection to health and community-based resources.
Requirements
- Manage and maintain a caseload of PHM members, with a primary focus on those with behavioral health and social needs, while coordinating with the care team on medical needs as appropriate.
- Conduct comprehensive assessments and develop individualized, person-centered care plans in collaboration with members, caregivers, and providers.
- Support members with behavioral health needs, including serious mental illness (SMI) and/or substance use disorders (SUD) through linkage to appropriate services.
- Provide culturally appropriate education to members and caregivers regarding behavioral health, chronic disease self-management, and community resources.
- Track member outcomes and document all encounter, interventions, and care plan updates in the Case Management (CM) system in compliance with organizational standards.
- Build and maintain collaborative relationships with providers, community agencies, and social service organizations to facilitate referrals and care coordination.
- Engage members using evidence-based approaches such as Motivational Interviewing to promote collaboration, increase member activation, and improve self-management skills.
- Provide brief crisis intervention and warm hand-offs to appropriate resources as needed.
- Support transitional care services by coordinating discharge planning, scheduling post discharge provider or TOC Clinic appointments, reconciling social/behavioral needs, and connecting members to ongoing supports to reduce avoidable readmissions and ER visits.
- Provide navigation and coordination of long-term services and supports (LTSS), ensuring members and caregivers are connected to appropriate programs that promote independence, stability, and quality of life.
- Address members’ social determinants of health (SDOH) by identifying needs such as housing, food insecurity, transportation, financial instability, or caregiver support, and facilitating access to community-based resources and services.
- Support members in strengthening skills that enable them to manage their conditions, identify and access needed resources, prevent complications, and maintain independence.
- Ensure care is continuous and integrated among all service providers by coordinating and following up with primary care, behavioral health, substance use treatment, LTSS, oral health, palliative care, and necessary community-based and social services, including housing.
- Ensure closed-loop referrals by confirming that services were received and barriers resolved.
- Participate in Interdisciplinary Care Team (ICT) meetings and case conferences to support care planning and coordination.
- Provide member advocacy by communicating needs, preferences, and goals to care teams in a timely and effective manner.
- Ensure documentation is accurate, timely, and compliant with regulatory standards.
- Attend mandatory departmental and staff meetings and contribute to process improvement initiatives.
- Assist with the training and orientation of new staff.
- Perform other duties as assigned.
Benefits
- Medical
- Dental
- Vision
- Paid Time Off (PTO)
- Floating Holiday
- Simple IRA Plan with a 3% Employer Contribution
- Employer Paid Life Insurance
- Employee Assistance Program
