BON SECOURS RICHMOND - VIRGINIA HEALTHSOURCE INC
In the capacity of a Social Worker, provide clinical care management services to identified eligible patients, coordinating care to obtain desired health outcomes, improve self-care abilities, and decrease unnecessary cost of care. Work as a member of Interdisciplinary Team (IDT) along with the Ambulatory Care Manager (ACM) and Care Coordinator to ensure the assigned patient's individual needs are identified and addressed in a timely manner. Perform standardized comprehensive needs assessment, identifying and addressing barriers to care and aligning patients with available benefits and resources.
Essential Job Functions:
Maintain a caseload of patients according to department policies.
Identify, enroll and manage patients in program for Complex Case Management.
Develop and implement care plans to maximize wellbeing with periodic review and update according to department protocols.
Collaborate with ACM, PCPs, Specialists, and Hospitalists to effectively implement a patient-centered care plan.
Perform situational and family assessment of social determinants of care and develop goals as part of the comprehensive care plan.
Perform patient outreach according to established protocols and document in electronic medical record
Identify, execute, and track needed referrals to care and community resources
Provide resource management to improve care, patient experience and reduce unnecessary cost and utilization: right care, right place, and right time
Assist patient in advanced care planning to complete Advanced Directives
Document all communications with patient and/or care team in electronic medical record
Perform coordination of services for disabled status and/or facilitate placement in post-acute facility for rehabilitation or long term care
Act as patient advocate to address primary physical and socioeconomic needs and link patient to appropriate community resources and services
Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served on his or her assigned unit
Demonstrates knowledge of the principles of growth and development of the life span and possesses the ability to assess data reflective of the patient's status and interprets the appropriate information needed to identify each patient's requirements relative to his or her age, specific needs and to provide the care needed as described in departmental policies and procedures.
Neonates (0-4 weeks)
Infant (1-12 Months)
Pediatrics (1-12 years)
Adolescents (13-17 years)
Adults (18-64 years)
Geriatrics (65 years and older)
Required Minimum Education: Bachelor's Degree
Preferred Education: Bachelor's or Master's Degree Specialty/Major: Social Work
Master's Degree or Licensure as required by that state of practice
Case Management certification, LSW or LCSW
Minimum Years and Type of Experience:
2-3 years of acute care, home health or case management experience
Other Knowledge, Skills and Abilities Required:
Excellent interpersonal communication and negotiation skills. Strong analytical, data management and computer skills. Demonstrate basic knowledge of healthcare and health education across the lifespan in a practice health setting. Ability to work with individuals, groups and families. Familiarity and knowledge of Community Resources. Flexibility to work non- traditional hours. Works well in a Team Setting. Personal computer skills. Experience with database entry, EMR documentation, Power Point preferred and basic Excel skills. Highly organized and detail oriented. Accepts responsibility and follows through on projects and activities
Other Knowledge, Skills and Abilities Preferred:
Demonstrates success by improving the health of a distinct population of patients in the ambulatory or community setting
Bon Secours Health System, Inc