Social Worker

HealthCare Partners, IPA and HealthCare Partners, MSO together comprise our health care delivery system providing enhanced quality care to our members, providers and health plan partners. Active since 1996, HealthCare Partners (HCP) is the largest physician-owned and led IPA in the Northeast, serving the five boroughs and Long Island. Our network includes over 6,000 primary care physicians and specialists delivering services to our 125,000 members enrolled in Commercial, Medicare and Medicaid products. Our MSO employs 165+ skilled professionals dedicated to ensuring members have access to the highest quality of care while efficiently utilizing healthcare resources.

About the role

The Social Worker will provide telephonic member engagement to facilitate comprehensive assessments and individualized interventions to help members achieve improved health outcomes. This position provides clinical experience working with a diverse population to address social determinants of health, mental health, substance abuse, and long-term care planning concerns. Services include assessments, treatment planning, hospital discharge planning, care coordination, and provision of counseling and crisis interventions.

The Licensed Social Worker will work in partnership with our network of physicians to address social needs of our population. They will be a member of the interdisciplinary team and collaborate with other team members including nurses, Clinical Pharmacist and Medical Directors to support all members through early discharge planning, psychosocial assessment, and care coordination, ensuring safe transitions of care while addressing social determinants of health and reducing avoidable utilization.

Responsibilities

• Incorporates knowledge of community resources and entitlement programs in planning, knows how to make appropriate referrals to community and other governmental agencies for services, and demonstrates ability to coordinate services.
• Independently assess the psychosocial functioning and needs of members to formulate and implement a treatment plan, identifying the member’s problems, strengths, weaknesses, coping skills, and connect them with additional services/resources, as appropriate.
• Proficient in motivational interviewing to assess and encourage change.
• Work from a strength-based, member-centered perspective to independently conduct psychosocial assessments and provide psychosocial treatment to a wide variety of individuals from various socio-economic, cultural, ethnic, educational, and other diverse backgrounds for our care coordination programs (behavioral health case management, episodic social work, and episodic behavioral health care management).
• Take ownership of each member contact to anticipate member needs, resolve their issues, and connect them with additional services/resources, as appropriate.
• Knowledge and experience in the use of medical and behavioral health diagnoses, psychiatric medications, and treatment procedures.
• Conduct behavioral health utilization management in accordance with MCG and ASAM criteria, participate in discharge planning, and encourage enrollment in behavioral health case management.
• Coordinate discharge planning activities with an interdisciplinary team.
• Actively participate in SNP (Special Needs Population) rounds, interdisciplinary inpatient, and skilled nursing facility rounds.
• Interact with hospital discharge planning team (i.e., hospital social workers, case managers, and case management staff) for the collection of pertinent information for timely discharge planning and linkage to appropriate community resources.
• Demonstrate an understanding of the SDOH and/or psychosocial needs of members and the impact of SDOH and/or psychosocial problems on the member’s well-being and compliance with treatment.
• Interact with medical directors to discuss member’s treatment plans.
• Conduct assessments with high-risk members with chronic conditions (i.e., ESRD on HD, severe diabetes, etc.) to assess barriers to receiving care and provide assistance.
• Act as a bridge between HCP and doctor offices to increase awareness of the SW and BH department and how social workers can assist them in managing their patient’s behavioral health and social needs; conduct PCP office visits as appropriate.
• Knowledge and skill in the use of computer software applications for drafting documents, data management, and tracking.
• Provide crisis intervention and stabilization as needed. May require some after-hours and/or weekend follow-up for emergency situations.
• Demonstrate excellent interpersonal skills and work well in a team.
• Demonstrate active listening skills and proficient documentation skills.
• Complete assigned training and webinars in a timely manner.
• Identify departmental program needs and make recommendations.
• Participate in special projects as assigned.

Requirements

• NYS license – Master/Clinical Social Worker
• MSW required
• 2-3 years of case management and/or hospital discharge planning experience

Skills

• Interpersonal skills with diverse groups
• Ability to efficiently problem solve
• Excellent organizational skills
• Ability to work independently as well as a team member
• Knowledge of community and governmental agencies
• Knowledge of clinical diagnosis and treatment modalities

Pay

Base Compensation: $70,000.00 - $85,000.00 annually

Bonus Incentive: Up to 12.5% annually based on organizational performance

Benefits

• Fully paid Medical & Dental employee coverage
• Robust benefits package including PTO, 401k, FSA, and Tuition Reimbursement