Community Social Worker (MSW)

WELLBE INTRODUCTIONThe WellBe care model is a Physician Led Advanced Practicecliniciandriven geriatric care (care of older adults) team focused on the care of the frail, poly-chronic, elderly Medicare Advantage patients. This population is typically underserved and very challenged with access to care. To address these problems, we have elected to bring the care to the patient, instead of trying to bring the patient to the care. Care is provided throughout the entire continuum of care - from chronic care and urgent care in the home, to hospital, to skilled nursing facility, to assisted living, to palliative care, to end of life care. WellBe's physician/advanced practicing clinician led geriatric care teams’ partner with the patient’s primary care physician to provide concierge level geriatric medical care and social support in the home as well as delivering and coordinating across the entire care continuum.GENERAL SUMMARYOur Social workers (MSW) are part of a team that provides compassionate care to the frailest elderly who have chronic and acute illnesses or injuries living in their homes. Our MSW coordinates traditional social work referrals and community outreach to address the needs of patients with social and behavioral problems and social determinants of health issues. The MSW will be accountable for caring for patients, connecting patients and their families to support services, maintaining accurate and current patient records and scheduling follow-up appointments to patients for these services as required. The successful candidate will work as a team with our physicians, advanced practice providers, and behavioral health specialists to deliver quality care. We offer a supportive work environment focused on compassionate patient-centered care, innovation, and collaboration.WellBe MSW - Social Worker - What to Expect:Practices the WellBe mission: To help our patients lead healthier, meaningful lives by delivering the most Complete Care.Telephonic outreach to patients and providers requesting assistance with community resources and social determinant of health needs.Develop plan of care responding to patient requests and assessment outcomes.Provide community resource coordination for patient requests and psychosocial problems.Collaborate efforts with multidisciplinary team to identify and respond to patient psychosocial needs.Develop and organize WellBe community resource directory.Utilize internally approved computer systems to identify internal and external resources.Document assessment and patient encounters following WellBe standards and best practices.Builds rapport with patients and their families and relay all concerns to WellBe provider/IDTCoordinates with other healthcare providers, agencies and community resources in order to create a thorough treatment plan addressing social, cultural, and financial needsCollaborates with the interdisciplinary team and participate in regularly scheduled team meetingsEnsures compliance with regulatory agencies and WellBe clinical guidelinesPartner with community team to refer patients to appropriate no or low-cost community services that support health and independence such as Meals On Wheels (MOW), local Area Agencies on Aging (AAA), Senior & Assistance Programs, and transportation resources.Involves the patients’ families and primary caregiver(s) as needed to achieve the best care decisions and outcomes.Effectively collaborates with all those involved in the members’ care, including health services contractors (i.e., Home Health, Hospice, Community Agencies), to meet the patients’ care goals.Complies with safety policies and procedures, identifying and immediately reporting any potential or actual unsafe acts or conditions to their supervisor/team. Takes necessary measures to ensure a safe environment for oneself, co-workers, contractors, participants, visitors and others.Consistently meets or exceeds WellBe targets for productivity, customer service, quality assessment, and performance targets.Understands the importance of community involvement and participates as appropriate in activities that link WellBe to its communities.Maintains current written progress notes and other documentation on the member Medical Record including signed and dated documentation for all service performed the day the service is provided.Participates in program and policy development of the WellBe Social Work program.Other tasks needed to accomplish team’s objectives/goalsQUALIFICATIONSEducational/ Experience Requirements:Master’s Degree in Social WorkTwo years social work experience, preferably in health care and case management, and minimum one-year experience working with a frail/elderlypopulation.License, Certification, RegistrationMSW requiredRequired Skills and Abilities:Age specific competency in working with the elderly and knowledge of community services forthe elderly and theirfamilies.Ability to develop appropriate care plansaccording to the patient needsMust be familiar with EHR medical documentationStrong computer skills, including Word, Excel, and PowerpointStrong verbal and written communication skillsBilingual in English/Spanisha plus.Ability to work effectively in a teamenvironment.Knowledge of social work principles and practices, including case management and advocacy.Ability to leverage internal and external resources as part of a patient’s care planExperience writing assessments and reports to monitor client progressValid driver’s license, have access to a car and willingness to drive to patient homes/patient location as well as an active auto insurance policyTravel requirements: Local travel may be required up to 80% of the time.Work Conditions: Ability to lift up to 20lbs. Ability to stand for extended periods.Ability to drive to patient locations (ie. home, hospital, SNF, etc). Fine motor skills/Visual acuity

Created: 2024-10-19