About this role
Primary Functions:
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· Responsible for patient outreach, assessment, disease management, and care coordination to patients with high rates of medical and behavioral health utilization and/or psychosocial vulnerability
· Assess patients through telephonic and eventually face to face encounters
· Builds a collaborative relationship with patients and their identified support system to encourage care participation and improve self-management of needs
· Utilize motivational interviewing to identify barriers and facilitate care plan compliance
· Effectively educate patients about healthcare delivery, plan benefits and a variety of topics related to health, and community resources
· Coordinates timely and appropriate implementation of assessments, care plans, and interventions for the identified patient population
· Provide medication reconciliation and support ongoing adherence
· Provide transitional care management
· Identify and helps to align patient care and community resources to prevent hospital readmissions and Emergency Department visits
· Document all activity in the documentation systems relevant to the role
· Collaborate with the care team to achieve high-quality, low-cost outcomes for patients.
· Interface and maintain positive relationships with key providers in the local hospitals, community practices, and organizations to ensure proper patient engagement and follow up
· Achieve established productivity targets
· Maintain compliance with the organization policies and procedures
· Demonstrate the ability to adapt, innovate and lead in a fast-paced environment, where change is common
· Passionate about making a difference in individual's lives
· Other duties as assigned
Qualifications:
• Requires a Master's in Social Work
• Must have a current full licensure as a LCSW by the NC Social work Certification and Licensure Board
• Two years post master's clinical experience is required
• Medical Social Work experience strongly preferred
• Knowledge of care management and quality principles are preferred
• Requires the ability to maintain confidentiality
• Must be able to interact with individuals of all cultures and level of authority
Additional skills required:
• Excellent and effective written and oral communication skills.
• Proficiency in Microsoft Office Outlook, Word, Excel, PowerPoint use and e‐mail communication.
• Ability to communicate clearly and succinctly.
• Dependable, manages time well; efficient and organized.
• Must be able to interact with individuals of all cultures and levels of authority.
• Requires the ability to maintain confidentiality.
Benefits:
• 401(k)
• Health, Dental and Vision insurance
• Employee assistance program
• AFLAC
• Paid time off