Social Worker *Baltimore ToC

About the role

The position involves home and facility visits in Baltimore, 4-5 days per week.

Responsibilities

• Evaluate members based on their needs and limitations based on referrals.
• Work directly with the Hospital/SNF case management staff to assist with the coordination of care and discharge plans for identified members.
• Collaborate directly with members and their families to build a rapport to assist with discharge needs as appropriate.
• Address member concerns and goals while maintaining constant communication with the member.
• Utilizes clinical judgement to assess members, prioritizing emerging issues to maintain a member-centric approach.
• Collaborates with interdisciplinary care team at the facilities to support member health goals via conference calls, rounds, and consultation, which may include face-to-face meetings.
• Complete assessments to better understand the Social Determinants of health and social issues impacting member care goals.
• Utilizes problem-solving skills to research and identify community resources and coordinate a referral mechanism.
• Plans specific objectives, goals, and actions designed to meet the members’ needs as identified in the assessment process that are action-oriented, time-specific, and cost-effective.
• Implements specific activities and/or interventions that lead to accomplishing the goals outlined in the plan of care.
• Develop trusting relationships with members by providing support and advocacy to help achieve health goals.
• Makes connections with members through visits to the hospital, home, and community via face-to-face, telephonic and/or video conferencing.
• Participates in outreach activities to promote knowledge of the program and its services and to coordinate program activities with outside community agencies and health care providers.
• Works with the MPC Case Management Team for an appropriate transition of care.

Requirements

• Master’s degree in social work.
• Maryland state LMSW/LCSW or LCSW-C licensure.
• At least 1 year experience in a community-based, hospital, or discharge planning setting addressing social needs and care transitions.

Qualifications

• Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.
• Knowledge of community agencies and resources.
• Working knowledge of multi-system outreach programs related to health care delivery, clinical education, and health-related services.
• Ability to plan, implement, and evaluate individual member care plans.
• Knowledge of change management, behavioral change management, transportation/food/safety resources.

Skills

• Utilizes clinical judgement to assess members, prioritizing emerging issues to maintain a member-centric approach.
• Collaborates with interdisciplinary care team at the facilities to support member health goals via conference calls, rounds, and consultation, which may include face-to-face meetings.
• Completes assessments to better understand the Social Determinants of health and social issues impacting member care goals.
• Utilizes problem-solving skills to research and identify community resources and coordinate a referral mechanism.
• Plans specific objectives, goals, and actions designed to meet the members’ needs as identified in the assessment process that are action-oriented, time-specific, and cost-effective.
• Implements specific activities and/or interventions that lead to accomplishing the goals outlined in the plan of care.
• Develops trusting relationships with members by providing support and advocacy to help achieve health goals.
• Monitors care management activities, services, and members’ responses to interventions, to determine the effectiveness of the plan of care and the utilization of services.
• Evaluates the effectiveness of the plan of care in reaching desired outcomes and goals; makes modifications or changes in the plan of care as needed.
• Make connections with members through visits to the hospital, home, and community via face-to-face, telephonic and/or video conferencing.
• Participates in outreach activities to promote knowledge of the program and its services and to coordinate program activities with outside community agencies and health care providers.
• Works with the MPC Case Management Team for an appropriate transition of care.

Benefits

• Competitive pay.
• Affordable medical, dental, and vision plans.
• 100% employer Term Life Insurance.
• Short and Long-Term Disability.
• 401k Employer Match up to 4%.
• 20 days of PTO.
• Tuition assistance/professional development plans.

Pay

Details about pay are not specified in this posting.

Schedule

Details about the schedule are not specified in this posting.