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Responsible for patient outreach, assessment, disease management, and care coordination to patients with high rates of medical and behavioral health utilization and/or psychosocial vulnerability
Assess patients through telephonic and eventually face to face encounters
Builds a collaborative relationship with patients and their identified support system to encourage care participation and improve self-management of needs
Utilize motivational interviewing to identify barriers and facilitate care plan compliance
Effectively educate patients about healthcare delivery, plan benefits and a variety of topics related to health, and community resources
Coordinates timely and appropriate implementation of assessments, care plans, and interventions for the identified patient population
Provide medication reconciliation and support ongoing adherence
Identify and helps to align patient care and community resources to prevent hospital readmissions and Emergency Department visits
Document all activity in the documentation systems relevant to the role
Collaborate with the care team to achieve high-quality, low-cost outcomes for patients.
Interface and maintain positive relationships with key providers in the local hospitals, community practices, and organizations to ensure proper patient engagement and follow up
Achieve established productivity targets
Maintain compliance with the organization policies and procedures
Demonstrate the ability to adapt, innovate and lead in a fast-paced environment, where change is common
Passionate about making a difference in individual’s lives
Other duties as assigned
Job Details
Description
Primary Functions:
Responsible for patient outreach, assessment, disease management, and care coordination to patients with high rates of medical and behavioral health utilization and/or psychosocial vulnerability
Assess patients through telephonic and eventually face to face encounters
Builds a collaborative relationship with patients and their identified support system to encourage care participation and improve self-management of needs
Utilize motivational interviewing to identify barriers and facilitate care plan compliance
Effectively educate patients about healthcare delivery, plan benefits and a variety of topics related to health, and community resources
Coordinates timely and appropriate implementation of assessments, care plans, and interventions for the identified patient population
Provide medication reconciliation and support ongoing adherence
Provide transitional care management
Identify and helps to align patient care and community resources to prevent hospital readmissions and Emergency Department visits
Document all activity in the documentation systems relevant to the role
Collaborate with the care team to achieve high-quality, low-cost outcomes for patients.
Interface and maintain positive relationships with key providers in the local hospitals, community practices, and organizations to ensure proper patient engagement and follow up
Achieve established productivity targets
Maintain compliance with the organization policies and procedures
Demonstrate the ability to adapt, innovate and lead in a fast-paced environment, where change is common
Passionate about making a difference in individual’s lives
Other duties as assigned
Qualifications
Requires a Master’s in Social Work
Must have a current full licensure as a LCSW by the NC Social work Certification and Licensure Board
Two years post master’s clinical experience is required
Medical Social Work experience strongly preferred
Knowledge of care management and quality principles are preferred
Requires the ability to maintain confidentiality
Must be able to interact with individuals of all cultures and level of authority
Additional Skills Required
Excellent and effective written and oral communication skills.
Proficiency in Microsoft Office Outlook, Word, Excel, PowerPoint use and e‐mail communication.
Ability to communicate clearly and succinctly.
Dependable, manages time well; efficient and organized.
Must be able to interact with individuals of all cultures and levels of authority.
Requires the ability to maintain confidentiality.
Benefits
401(k)
Health, Dental and Vision insurance
Employee assistance program
AFLAC
Paid time off
Seniority level Seniority level Entry level
Employment type Employment type Full-time
Job function Job function Health Care Provider
Industries Hospitals and Health Care
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