The Care Coordination MSW Social Worker works in collaboration with a multidisciplinary team of clinicians as part of the Care Coordination program to provide high quality, outcome-based, patient-centered care and address the social determinants of health to support safe transitions of care across the continuum for patients and families throughout Atlantic Health System.
 

Job Function: 01.

Support high-cost/high-risk patients to address barriers to care and navigation challenges across the care continuum by prioritizing health and SDOH needs, addressing gaps in internal and external resources, and sustainable connections to medical homes and sustainable social supports to improve the patient experience, achieve better health outcomes, decrease avoidable cost and utilization, and increase the utilization of preventative care and healthy behaviors to improve health.

Job Function: 02.

Provide psychosocial assessment, sustainable care transitions, and structured support to help address social and economic barriers to positive health outcomes and empower patients to set and achieve their individualized health goals. Apply best practice interventions based upon care standards and referral and linkage to services to ensure behavioral and psychosocial needs are addressed, including but not limited to: social needs, financial stressors, difficulty coping, behavioral health concerns or substance misuse, abuse and neglect, interpersonal violence, homelessness, functional decline, frequent ED visits or hospitalization, need for long-term care planning, etc.

Job Function 03.

Maintain best practices, process systems, and key performance metrics to provide effective outcome-based, patient-centered care with a focus on culturally-sensitive and inclusive interventions, equitable access to care, and reduction in health disparities. Conduct psychosocial assessment, social determinants of health screening and referral, and develop a plan of care in alignment with individual needs, values, and goals of the patient. Provide individual telephonic/virtual support and counseling to patients, using appropriate therapeutic techniques and evidence-based theories to guide patients toward healthy coping, self-management, and overall wellness. Maintain accurate and timely referral response, assessment, intervention, and documentation, according to department workflow and policy.

Job Function 04.

Ensure ongoing collaboration and communication with the larger interdisciplinary Care Coordination team, AHS/ACO practices, providers, and care team members to comprehensively address evolving psychosocial needs, medical needs, and plan of care. Maintain a current knowledge base of community agencies and key contacts and assist with patient advocacy, navigation, and engagement with sustainable medical, social, insurance and benefit systems. 

Job Function: 05.

Regularly attend and actively participate in assigned intradisciplinary and interdisciplinary forums, administrative meetings, staff meetings, supervisory sessions, and in-service training. Provide consultative support for department community health workers through education, training and one to one case oversight. Annually participate in a minimum of 3 educational programs on topics relevant to practice area.  

Job Function: 06.

Other tasks as required by manager, director, or leadership.