Assess and evaluate member's needs and requirements to achieve and/or maintain optimal wellness state
Engage patients identified as high-risk and implement targeted interventions to address social needs
Provide guidance and oversight of care coordination efforts to other members of the team
Handle clinical escalations as indicated
Conduct Transitions of Care Management for a subset of the patient population
Provide triage guidance and supportive consultation to other team members
Develop care plans leveraging 5Ms Geriatric best practice framework
Identify existing barriers to engagement with necessary resources and supports
Serve as liaison between the patient and the direct care providers
Document patient encounters in the medical record system in a timely manner
Requirements
Master's in Social Work (MSW)
Minimum of 4 years of experience working in healthcare services and navigating community-based resources
Strongly prefer Bilingual Spanish/English
Familiarity with state Medicaid guidelines and application processes preferred
Experience working with patients with behavioral health conditions and substance use disorders preferred
Prior experience conducting home visits and knowledge of field safety practices preferred
Benefits
Health benefits effective day 1
Paid time off, holidays, volunteer time and jury duty pay
Recognition pay
401(k) retirement savings plan with employer match
Tuition assistance
Scholarships for eligible dependents
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
care coordinationcare plansTransitions of Care Managementtriage guidancebehavioral healthsubstance use disorderscommunity-based resourcesfield safety practices