Population Health Leader
Population Health Leader works as part of a multidisciplinary ambulatory care team to serve patients with complex social, environmental, and mental health needs that prevent them from reaching their health goals.
The Population Health Leader will: provide complex care management services for patients from across the clinic; and will provide diagnostic assessment and short term behavioral counseling within dedicated clinic hours.
Duties and Responsibilities – Population Health Leader will:
• Support Social Work Team Lead in oversight of and response to requests for Care Management services handled by Population Health Specialist/Care Management Intake Coordinator.
• Provide direct complex care management as indicated or directed to assist patients with multiple chronic illnesses through assessment, counseling, care management, psychoeducation, advocacy and linkage to long-term community and home based services, advocacy, and facilitation of continuity of care and coordination of services.
• Conduct biopsychosocial assessment including social determinants of health, with patients to assess and determine community supports (food, transportation, mental health programs, substance abuse programs, etc.) available to them in efforts to improve their quality of life.
• Conduct assessment to determine need for medical treatment, and/or need for higher level or continuity mental health, substance abuse, and psychiatric services.
• Provide care management support to bridge patients to appropriate outside support services.
• Use brief solution focused interventions along with psychoeducation and motivational interviewing with patients to assist in meeting patient stated self-care management and mental health goals.
• Provide clinical diagnostic assessments of counseling patients and short term evidenced based Problem Solving Treatment to address program scope clinical issues that impact health and self-care management; refer or bridge to higher level, specialized or continuity services as indicated.
• Work in collaboration with physicians, advanced practice providers, nurses, other LCSWs, psychiatrists, pharmacists, and other care partners to serve Care Management and Counseling patients.
• Provide support for Hospital Follow Up Clinic to reduce hospital readmissions by providing patients with connections to social, emotional, and financial supports in their community, and will complete biopsychosocial assessments to determine barriers to care and risk for readmission.
• Support clinic with 30 day transitions workflow including running reports, distributing patients among team members and conducting follow up for select patients thirty days post discharge.
• Assist physicians and clinic staff in working with at-risk in clinic patients or callers.
• Connect patients with appropriate emergency mental health services and when necessary help to facilitate hospitalization to ensure patient safety.
• Assist in maintaining updated electronic medical record patient Resource Smartphrase Lists.
• Maintain timely, professional documentation and contribute to program reporting of work.
• Other duties and responsibilities as needed and directed
This position is overseen by Social Work Team Lead and directly supervised by Population Health Senior Leader/Director of Social Work. This position works in collaboration with the Social Work Team to address Internal Medicine Clinic social work related issues. This is a complex care management position that also includes conducting short term evidenced based counseling clinics. This position takes responsibility for coordinating and implementing a patient’s care plan, either alone or in conjunction with a team of health professionals. Delivers high quality, efficient care through patient engagement and education, improved care coordination and successful implementation of care plans. Collaborates with patients and members of the health care team to identify appropriate utilization of resources and to ensure reimbursement.
Qualified clinical social worker will serve patients with complex social, environmental, and mental health needs that prevent them from reaching their health goals. The patient population served is socioeconomically, ethnically, and culturally diverse and includes Medicaid, Medicare, uninsured, and private payers. The optimal candidate will be knowledgeable about, and preferably experienced in, work addressing: home health; housing; food insecurity; mental health; substance abuse; other areas of patient support; and end of life care. The licensed clinical social worker will have experience in work with an interdisciplinary care team, preferably in a primary care setting. This position will work closely with a team of clinical social workers and other care partners.
Licensed Clinical Social Worker preferred. Prefer experience with complex care management and resources, work with end-of-life planning, work with vulnerable populations, experience in short term goal-focused behavioral counseling for primary care. Bilingual ability with Spanish and English speaking preferred.
Master’s degree in Social Work (MSW) from a program accredited by the Council on Social Work Education or graduation from a state accredited school of professional nursing. Five (5) years of experience in a health care setting.
Primary Location: Chapel Hill, North Carolina, United States
Department: P-31331-SOM GEN MED CLINIC
Shift: Day Job
For UNC employee candidates, internal link, go in through myHR Portal > myCareer >enter job ID # 5772