Position Purpose: Under general direction of the Director of Behavioral Health, the Social Services Team Lead oversees, monitors and coordinates the daily operations of Steward Health Care Network's Social Services programs (General and Homeless). The Social Services Team Lead is a core member of Steward's collaborative care team, providing care management and care coordination to manage members impacted by homeless/housing instability and Social Determinants of Health (SDOH). The Social Services Team Lead works closely with the patient's care team to develop, implement and evaluate a plan of care tailored to the patient's unique needs. The Social Services Team Lead provides support and/or intervention and assists members in understanding the implications and complexities of their current situation and/or overall personal care.
Provides oversight on a daily basis including but not limited to staffing assignments, crisis management or as directed by the Director of Behavioral Health
Provides education and support to the Social Services Team or as requested by other SHCN Programs, when there are challenging cases or topics requiring subject matter expertise at the direction of the Director of Behavioral Health
Demonstrates leadership that fosters a positive culture of continuous improvement in the department
Documents and reports all quality and patient safety events by recording and adhering to all of Steward Health Care Network's safety reporting guidelines
Provides clinical/licensure supervision to staff requiring supervision to work towards licensure and/or staff who require additional clinical feedback/support.
Works collaboratively with the Director of Behavioral Health to determine and achieve programmatic performance targets
Demonstrates leadership that creates and fosters a positive culture of continuous improvement in the department.
Demonstrates ability to positively adapt to changes within an evolving program.
Ability to lead and motivate others to execute a plan in a rapidly changing environment.
Positively reinforces expectations set by Director of Behavioral Health to team including but not limited to documentation, enrollment targets, case duration, engagement in team meetings, etc.
Provides telephonic care coordination services to high risk patients that are impacted by Social Determinants of Health such as: homelessness/housing instability, food insecurity, financial resources, legal assistance, transportation, applying for disability, accessing services, application assistance, etc.
Provides advocacy, patient education and support in accessing community-based and hospital-based programs.
Utilizes resources of public and private agencies and community organizations to meet the needs of patients and families.
Assists patients with organizing their records, making follow-up appointments, and filling their prescriptions.
Helps patients fill out applications, for example for Medical Assistance and SNAP (Supplemental Nutrition Assistance Program)
Makes referrals to case managers, as appropriate, and/or refers patient's family to community support services and resources.
Schedules and completes initial assessment, develops a patient-centric plan of care and schedules follow-up within specified timeframes
Initiates telephonic or face to face contact with high risk patients of all ages to conduct a Care Needs Screening
Evaluate Care Needs Screening responses and make appropriate referrals to internal care management programs or to external resources.
Records and monitors the participants' progress toward goals within specific timeframes
Collaborate with youth and family service agencies at the local, county and state level including but not limited to schools, special education services, DCFS, family court systems.
Works collaboratively with the members PCP and/or other key providers in planning and directing each patient's treatment program
Clearly documents all activities in the patient record
Provides concise and thorough documentation through psycho/social assessment and progress notes, including changes in medical psycho/social functioning, progression and attainment of goals, referrals to internal and external agencies, and contact/involvement with patient's family.
Demonstrates cultural sensitivity and respect for the patient
Years of Experience:
Work Related Experience:
Experience working with the needs of vulnerable populations who have chronic or complex psychosocial needs
Experience working with disadvantaged populations, preferred
Experience in a managed care environment and case management experience, preferred
Must be able to effectively communicate, present and explain complex material with patients, family members, case managers, treating physicians and community organizations
Must possess the interpersonal skills to engage children and adolescents of varying ages and families in helping relationships.
Must be able to cope with the pressure of time limitations while respecting the needs of the patient and the requirements of the organization/department.
Ability to take action in solving problems while exhibiting sound judgment and a realistic understanding of issues; able to use reason, even when dealing with emotionally charged topics.
Ability to remain open-minded and change opinions on the basis of information, perform a wide variety of tasks and change focus quickly as demands change, and manage transitions effectively from task to task.
Must possess a strong belief in an organizational culture that encourages valuing and best service excellence practices demonstrated through personal behavior and work ethic.
Ability to travel, including valid driver's license and auto liability insurance coverage according to company policy.
Must possess the ability to present and explain complex material to physicians and other providers and member populations in a professional manner.
Ability to work in several databases and to comply with established documentation requirements
Exceptional organizational skills; ability to multi-task and work independently and part of a team
Demonstrate ability to prioritize, multitask, and work in a rapidly changing environment with multiple demands
Working knowledge of government and community based resources and delivery systems needed to assist patients to address homelessness/housing instability/Social Determinants of Health.
Experience providing resource information and continued support to patients to ensure access to services to address homelessness/housing instability/Social Determinants of Health utilizing culturally sensitive practices.
New England Sinai Hospital And Rehabilitation Center