Social Work Coordinator
Job Summary
We are recruiting for a mission-driven Social Work Coordinator to join our team! We're with you for life’s journey. At Denver Health, purpose isn’t just something we believe in—it’s something we live every day, for life’s journey. Our Values Respect | Belonging | Accountability | Transparency
Department: ACS-CHS Grants Funded
Job Summary: Under general supervision, the Health Plan Denver Health Pediatrics at Denver Public Schools School-Based Health Center (SBHC) Social Work Care Coordinator (SWCC) is responsible for facilitating and coordinating the care delivered to an assigned group of patients members using multidisciplinary and member/family collaboration to ensure quality and cost effective outcomes are delivered within appropriate care coordination parameters. Coordination involves assessment of care needs, planning, support, and evaluation of member care and related outcomes. Activities to be performed are screening and assessment of medical, behavioral health and social determinants needs and gaps in care, collaboration with the Member to develop a care plan with SMART goals, scheduled outreach to support member in achieving their goals and supporting the Members' self-efficacy to navigate systems.
Essential Functions
Utilizes Care Coordination Processes: Systematically collects focused data relating health needs and concerns of member/patient, group, or population. Establishes and maintains member/patient-centered relationships. Analyzes assessment data to determine opportunities for health promotion, health maintenance or health related problem needs and statements. Identifies and executes evidence-based interventions to support the Member/patient in achieving their health goals. Identifies and works towards expected outcomes in a plan of care individualized for a specific member/patient, group or population. In collaboration with the patient/Member, develops a care plan that identifies strategies and alternatives to attain expected outcomes. Utilizes competent, evidence based, telephone encounters and electronic communications according to regulatory requirements and standards, as well organizational policies and procedures. Conducts systematic evaluation of outcomes of care coordination in relation to structures and processes prescribed by plan/determined by grant.
Provides Care Coordination Services: Coordinates the delivery of care within the clinic setting, throughout the organization, and across health care settings. Provides relevant information across the care system, within Denver Health and with other healthcare systems and payers when member care is transferred between and among different specialties and/or within one or more organizations. Provides information to the health care team including the member/patient, family, and caregiver regarding available resources and benefits for health care services that ensures member choice and safe, timely transition. Serves as point of contact within and among healthcare services and organizations. Coordinates community resources. Assures designation of primary responsibility among team members for each aspect of care plan, avoiding duplication and fragmentation. Facilitates continuity of care using the multidisciplinary collaboration, and coordination of all appropriate healthcare services and community resources across the care continuum. Orients member/caregiver/patient to health care delivery system, services, access, and resources.
Health Teaching and Promotion: Identifies barriers to goals and strategies to address. Provides personalized education for optimal wellness. Encourages preventative care such as immunizations and cancer screening. Well Child Checks. Promotes appropriate utilization of resources. Assists and educates caregiver when member is unable to participate. Incorporates therapeutic communication, health literacy, cultural, and linguistic needs and preference into education and goals. Supports members/patients and caregivers in developing skills for self-efficacy to promote, maintain, or restore health such as healthy lifestyle tips, risk-reducing behaviors, age and developmental needs, daily living activities, and preventative care.
Care Coordination Responsible for a defined caseload of Members enrolled in the DHMP Medicare Choice Dually-eligible Special Needs Program (DSNP) patients who are identified as having a medium or low risk acuity level using data from a variety of sources, including the Member/patient, their caregivers, providers, administrative claims data, pharmacy data and other inputs. The DSNP Model of Care is a well-defined model requiring a comprehensive health risk assessment (HRA), individualized care plan (ICP) and integrated care team (ICT) review of the ICP. This routine is completed at least annually and more frequently when the Member experiences a change in condition, as evidenced by hospitalization, movement to a residential place of care or other event. Obtains Member/patient consent to participate in the program as well as to share clinical information with the Member’s patient’s care team. Works collaboratively with the patient/Member to set SMART (specific, measurable, attainable, realistic and time-limited) goals. and to graduate the Member to lower-intensity care programs and self-care within reasonable timeframes. Works under the supervision and advice of the Supervisor who can provide insight into medical conditions, treatments, medications and answer medically-related questions as needed.
Education
High School Diploma or GED Required
Work Experience: 1-3 years Direct member care experience in acute, ambulatory care or community based care Required
Licenses: Knowledge of emotional and social factors that impact patient’s health. Excellent interpersonal skills. Skilled in identifying problems/opportunities to improve care. Ability to help the patient and family to understand, accept, and follow medical recommendations. Ability to utilize resources, such as family or community agencies, to assist the patient to resume life in the community. Ability to collect key information from the patient, family, and the community, as part of the social work assessment. Ability to communicate to the appropriate staff, information about the patient’s discharge plan. Experience with windows-based computer programs and ability to use computer for data analysis and data display, required. Experience with Medical Management platforms used to document care coordination services, preferred.