Palliative Care Social Work Case Manager

About the role

A bit about this role This specific role provides Social Work support to our Palliative Care Program. Devoted’s virtual Palliative Care program serves members with complex needs and life-limiting illness who otherwise would not have access to specialized palliative care. We pride ourselves on providing highly compassionate, patient-centered goals of care counseling and symptom management for members projected to be in the final year of life. We meet patients where they are and support them in defining quality of life, achieving meaningful goals, and transitioning to hospice care. As a Palliative Care Social Work Case Manager, you will serve our patients as an advocate, coach, and connector - working closely with patients, caregivers and other members of the team to identify and eliminate socioeconomic and psychosocial barriers and provide supportive counseling. This role will require you to develop individualized care plans that align community, clinical, and patients’ personal resources. You will provide coaching on improving coping skills, self-management, and caregiver assistance, re-enforce disease-specific education and facilitate goals of care and advanced care planning discussions, including hospice care transitions when appropriate.

Responsibilities

• Telephonic and video visits with patients and caregivers
• Establish trust and build strong relationships with our patients
• Interdisciplinary collaboration with teammates (including clinicians, nurses, and care coordinators) to ensure cohesive, patient-centered care for high-needs patients
• Conduct Social Work interventions to maximize the effectiveness of the program
• Conduct psychosocial assessments and create personalized care plans tailored to members’ needs
• Provide emotional and caregiver support
• Assist in navigating complex family/support issues
• Complete goals of care conversations and advanced care planning
• Conduct long term care planning and placements
• Place/follow through on behavioral health referrals
• Investigate concerns for patient abuse or neglect
• Know how to balance multiple competing priorities from complex patients
• Work with family members/caregivers to help them in understanding the member’s needs and how they can be supportive
• Manage or lead conversations with patients, caregivers, and family regarding goals of care, and social drivers of advanced care planning
• Facilitate and participate in family meetings and joint visits
• Participate in team huddles, panel reviews, interdisciplinary team rounds, and program/role growth and development
• Build relationships and coordinate with key local market and internal stakeholders
• Document all clinical interactions in the electronic health record

Qualifications

Required:

• Master’s degree in social work and active license
• Minimum of 2 years expertise in palliative or hospice with proficiency in leading goals of care conversations, assisting with advanced care planning, and supporting people through grief, loss, and bereavement
• Certified hospice and palliative social work credential, or willingness to obtain within one year of employment
• Comfortable with technology and a fast-paced environment
• Self-starter with ability to succeed in a work-from-home environment
• Strong interpersonal and communication skills
• Comfortable