Medical Social Worker

Medical Social Worker

Requirements

• Proactively support our highest-need patients by providing comprehensive assessments, telephonic check-ins, and in-person visits.
• Maintain extensive knowledge of community resources and make referrals, as appropriate, to help ensure the patient’s healthcare and psychosocial needs are met.
• Navigate patient insurance benefits in collaboration with the Patient Relations Manager (PRM) to ensure mindful utilization and maximization of plan benefits.
• Provide psychoeducation to patients and families surrounding life stage and disease-specific issues, including dementia, adjustment to illness, aging, caregiver support, etc.
• Respond to crises and urgent needs with the keen ability to prioritize work, triage situations, and multitask.

Responsibilities

• Partner with the patient and their support persons (if necessary) to identify goals, increase engagement in their healthcare, address barriers, and drive the execution of their care plan.
• Provide both longitudinal and episodic comprehensive care coordination with the ultimate goal of empowering patients to independently manage their health conditions and have increased quality of life.
• Educate patients on supportive care options (including advance care planning and end-of-life care) and provide goals of care counseling, support, and advocacy at all stages of the patient journey.
• Meet with care teams to collaborate and generate creative solutions to patient issues, and spearhead intervention in situations with complex psychosocial dynamics.
• Complete concise and comprehensive documentation on time to ensure that all care team members have visibility into the status of MSW interventions.
• Partner with Community Health Workers and provide clinical guidance and consultation regarding complex patient needs to these team members.
• Other duties as assigned.

Preferred Qualifications

No preferred qualifications provided.