Community Social Worker (MSW)

WELLBE INTRODUCTION

The WellBe care model is a Physician Led Advanced Practice clinician driven geriatric care (care of older adults) team focused on the care of the frail, poly-chronic, elderly Medicare Advantage patients.  This population is typically underserved and very challenged with access to care.   To address these problems, we have elected to bring the care to the patient, instead of trying to bring the patient to the care. Care is provided throughout the entire continuum of care – from chronic care and urgent care in the home, to hospital, to skilled nursing facility, to assisted living, to palliative care, to end of life care.  WellBe's physician/advanced practicing clinician led geriatric care teams’ partner with the patient’s primary care physician to provide concierge level geriatric medical care and social support in the home as well as delivering and coordinating across the entire care continuum.

GENERAL SUMMARY

Our Social workers (MSW) are part of a team that provides compassionate care to the frailest elderly who have chronic and acute illnesses or injuries living in their homes.  Our MSW coordinates traditional social work referrals and community outreach to address the needs of patients with social and behavioral problems and social determinants of health issues. The MSW will be accountable for caring for patients, connecting patients and their families to support services, maintaining accurate and current patient records and scheduling follow-up appointments to patients for these services as required. The successful candidate will work as a team with our physicians, advanced practice providers, and behavioral health specialists to deliver quality care.  We offer a supportive work environment focused on compassionate patient-centered care, innovation, and collaboration

WellBe MSW - Social Worker - What to Expect:

• Practices the WellBe mission: To help our patients lead healthier, meaningful lives by delivering the most Complete Care.
• Telephonic outreach to patients and providers requesting assistance with community resources and social determinant of health needs.
• Develop plan of care responding to patient requests and assessment outcomes.
• Provide community resource coordination for patient requests and psychosocial problems.
• Collaborate efforts with multidisciplinary team to identify and respond to patient psychosocial needs.
• Develop and organize WellBe community resource directory.
• Utilize internally approved computer systems to identify internal and external resources.
• Document assessment and patient encounters following WellBe standards and best practices.
• Builds rapport with patients and their families and relay all concerns to WellBe provider/IDT
• Coordinates with other healthcare providers, agencies and community resources in order to create a thorough treatment plan addressing social, cultural, and financial needs
• Collaborates with the interdisciplinary team and participate in regularly scheduled team meetings
• Ensures compliance with regulatory agencies and WellBe clinical guidelines
• Partner with community team to refer patients to appropriate no or low-cost community services that support health and independence such as Meals On Wheels (MOW), local Area Agencies on Aging (AAA), Senior & Assistance Programs, and transportation resources.
• Involves the patients’ families and primary caregiver(s) as needed to achieve the best care decisions and outcomes.
• Effectively collaborates with all those involved in the members’ care, including health services contractors (i.e., Home Health, Hospice, Community Agencies), to meet the patients’ care goals.
• Complies with safety policies and procedures, identifying and immediately reporting any potential or actual unsafe acts or conditions to their supervisor/team. Takes necessary measures to ensure a safe environment for oneself, co-workers, contractors, participants, visitors and others.
• Consistently meets or exceeds WellBe targets for productivity, customer service, quality assessment, and performance targets.
• Understands the importance of community involvement and participates as appropriate in activities that link WellBe to its communities.
• Maintains current written progress notes and other documentation on the member Medical Record including signed and dated documentation for all service performed the day the service is provided.
• Participates in program and policy development of the WellBe Social Work program.
• Other tasks needed to accomplish team’s objectives/goals

QUALIFICATIONS

Educational/ Experience Requirements: 

• Master’s Degree in Social Work
• Two years social work experience, preferably in health care and case management, and minimum one-year experience working with a frail/elderly population.

License, Certification, Registration

• MSW required

Required Skills and Abilities: 

• Age specific competency in working with the elderly and knowledge of community services for the elderly and their families.
• Ability to develop appropriate care plans according to the patient needs
• Must be familiar with EHR medical documentation 
• Strong computer skills, including Word, Excel, and Powerpoint
• Strong verbal and written communication skills
• Bilingual in English/Spanish a plus.
• Ability to work effectively in a team environment.
• Knowledge of social work principles and practices, including case management and advocacy.
• Ability to leverage internal and external resources as part of a patient’s care plan 
• Experience writing assessments and reports to monitor client progress 
• Valid driver’s license, have access to a car and willingness to drive to patient homes/patient location as well as an active auto insurance policy 

Travel requirements: Local travel may be required up to 80% of the time.

Work Conditions: Ability to lift up to 20lbs.  Ability to stand for extended periods.

Ability to drive to patient locations (ie. home, hospital, SNF, etc).  Fine motor skills/Visual acuity 

 The preceding functions may not be comprehensive in scope regarding work performed by an employee assigned to this position classification.  Management reserves the right to add, modify, or rescind the work assignments of this position.  Management also reserves the right to make reasonable accommodations so that a qualified employee(s) can perform the essential functions of this role