Care Coordination - Manning - Care Management - Licensed Social Worker

Care Coordination - Manning - Care Management - Licensed Social Worker

Manning House I, 450 W. Paseo Redondo, Tucson, Arizona, United States of America Req #6187 Saturday, October 19, 2024

Schedule : Monday - Friday

Pay Range : $30.50 - $44.17 Depending on Experience

JOB PURPOSE : The Care Coordination LCSW provides provision of a whole person, integrated, accessible, and equitable health care by interprofessional teams who are accountable for addressing the majority of an individual’s health and wellness needs across settings, and through sustained relationships with patients, families, and communities.

The Care Coordination LCSW works with patients and a multidisciplinary team to identify social determinants of health that are a barrier toward health equity.

Assesses and utilizes credible tools to evaluate social determinants of health and develop individualized care plans for the patient and family.

Prepares needs assessments and engages the multidisciplinary team to collaborate services and community resources. Improves understanding of access points for medical care, resulting in decrease emergency room visits and hospital admissions and re-admissions.

Essential Job Functions :

• Serves as ongoing primary contact for Care Coordination Registered Nurses who need assistance with care for their managed patients.
• Provides non-judgmental care to patients, taking into account assessment and motivational interviewing techniques, identifying psychosocial, physical, education, and linguistic needs.
• Develops a comprehensive individualized plan of care and targeted interventions that involve patient / family in the decision-making process.

Includes patient’s goals, preferences, and care team’s treatment goals.

Continually monitor’s patient / family response to plan of care and revise as needed. Interprets nature of illness and prescribed course of treatment to patients and families;

communicates family issues to other staff members; participates in planning conferences.

• Maintains records, patient registries, and documented follow up to ensure patients receive continuity of care whenever possible.
• Acts as a liaison between providers, provider teams, patients, families, and community, arranging transitions of care plans.
• Coordinates cases between the health care team and payors.
• Partnering with the Leadership team on initiatives focused on reducing emergency room visits and hospital admissions and re-admissions.
• Collaborates in ongoing innovation of the Care Coordination team.
• Provides services to all El Rio Health Centers staffed by a Registered Nurse Care Coordinator, in-person and via telephone.

Potential travels to various health centers throughout the work week to provide care.

• Coordinates access to community resources for patients needing socio-economic support, including food and shelter.
• Maintains an updated list of community resources.
• Using data systems to monitor gaps in care.
• Consistently demonstrates AIDET principles and serves as a role model for service excellence with all patients / visitors, colleagues, and the community.
• Maintains a clean, safe, and hygienic work environment in compliance with all Policies and Procedures including but not limited to work areas, workstations, examination rooms, hand washing, infection prevention and control etc. for this position.
• Demonstrates an understanding of and proficiency with the application of all compliance and reporting requirements respective to Joint Commission Certification (JCC) standards.

Minimum Education and Experience :

• Master’s degree in Social Work from an accredited college or university.
• Three (3) years’ experience working with patients in a healthcare or related environment.
• Experience doing care coordination.

If applicable, equivalent combination of education and experience may be considered, and must be directly related to the functions and responsibilities of the job.

Required Licenses, Certifications, and Registrations :

• Current Arizona state license as a Licensed Master Social Worker from the Board of Behavioral Health Examiners, State of Arizona.
• Current certification in Basic Life Support (BLS) for health care providers.
• Level I fingerprint clearance card : current valid and in good standing or have applied for it within seven working days after beginning employment.
• Employees in this position are required to have reliable transportation that can meet any operational reassignments of the organization during the workday.

If an employee is driving during work hours, the employee is required to possess a valid driver’s license and must comply with Arizona vehicle insurance requirements.

Preferred Education, Experience, Skills, Abilities :

• Five (5) years’ working experience in community health centers or primary care.
• Previous training in Crisis Intervention, Non-Violent Crisis Intervention, and / or related intervention care models.
• Bilingual (English / Spanish) with the ability to speak, read and write in both languages.

El Rio Health is a diverse and inclusive organization. We are invested in helping you and your family Create Tomorrow.