Job Summary:
Responsible for patient outreach and care coordination in the ambulatory practice setting. Identifies barriers to care plan compliance and provides appropriate education and resources. Works collaboratively with the care team to achieve high quality, low cost outcomes for patient populations. Consistently achieves established productivity targets.
Description of Job Responsibilities:
1. Provides care management services in the ambulatory practice setting. Works collaboratively with other care team members to develop and support the patient’s care plan.
2. Utilizes motivational interviewing to identify barriers and facilitate care plan compliance. Serves as a patient advocate, supporting shared decision-making and the use of decision aids.
3. Educates patients and families on a variety of topics including how to access medical home services, establish self-management goals, and navigate the health care system.
4. Identifies, coordinates and helps to align patient care and community resources to facilitate patient care transitions and prevent hospital readmissions and Emergency Department visits.
5. Provides psychotherapy for mental, emotional, addictive, behavioral, or developmental disorders and conditions within the scope of practice for a LCSW.
6. Reviews and monitors patient outcomes, recommends changes in care plan and implements population management interventions.
7. Appropriately documents consults and interventions in the patient’s electronic medical record.
8. Consistently achieves established productivity targets.
9. Appropriately documents consults and interventions in the patient’s electronic medical record.
10. Actively participates in meetings, problem solving, goal setting, quality improvement and patient satisfaction initiatives.
11. Maintains compliance with organizational policies and procedures and evidenced based guidelines.
Education Requirements:
Requires Master’s in Social Work.
Licensure/Certification Requirements:
LCSW required.
Professional Experience Requirements:
Three (3) years of broad clinical experience in the acute care setting caring for patients with complex medical conditions required. Experience in case management, utilization review, quality management preferred.
Knowledge, Skills, and Abilities Requirements:
Excellent interpersonal skills and communication capabilities. Knowledge of care management and quality improvement principles. Possess appropriate analytical skills to independently problem solve and make decisions. Possess computer skills at a level sufficient to effectively and efficiently use computer applications common to a Patient Centered Medical Home practice.
