Social Worker - Health Homes Care Management

Overview

St. John's Riverside Hospital is a leader in providing the highest quality, compassionate health care utilizing the latest, state-of-the-art medical technology. Serving the Westchester community from Yonkers to the river town communities of Hastings-on-Hudson, Ardsley, Dobbs Ferry and Irvington, St. John's Riverside has been and continues to be a unique and comprehensive network of medical professionals dedicated to a tradition of service that spans generations.

St. John's has been an integral part of the community since the 1890's and its' commitment to provide the community with the most advanced medical services available continues to be the hospitals' vision, mission and value. St. John's Riverside Hospital built itself around an early foundation of nursing and community service. In 1894, the Cochran School of Nursing, the oldest hospital-based school of nursing in the metropolitan area, was founded, thus making the St. John's Nursing Staff more than just the backbone of the hospital, but the heart and soul. St. John's dedicated nurses give superior attention to those who need it most with a strong emphasis on patient and family-focused nursing care.

St. John's Riverside Hospital staff is committed to making life better for all patients. The hospital continues to elevate the services provided with the goal of increasing the quality of life for all who entrust St. John's Riverside Hospital to their care.

St. John's Riverside Hospital is an equal opportunity employer. We maintain a policy of non-discrimination in providing equal employment to all qualified employees and candidates regardless of race, creed, color, national origin, sex, age, disability, marital status, or other legally protected classification in accordance with applicable federal, state, and local law.

Personalized care together with advanced technology is what it means to be Community Strong

Responsibilities

The Social Worker will be responsible for providing client centered, strengths-based care management services to ensure outreach, engagement, assessment, care planning development & implementation, coordination and monitoring of assigned clients. Through a collaborative effort with the client's care team, the Social Worker will coordinate and advocate for services that promote optimal health outcomes and reduce the usage of the Emergency Department and inpatient hospital stays.

1. Provide active and progressive outreach and engagement activities to ensure clients understand the available services and engage in appropriate programs with on-going involvement. Obtain program specific consent.
2. Conduct Comprehensive Intake Assessments within 30 days of initial consent or agreement to participate in the designated program as required by the program's funders. This shall include but not be limited to:

A. Program-specific Comprehensive Intake & Assessments packet
B. PHQ-9
C. HARP Eligibility Assessment (UAS)

3. Develop and implement individualized Care Plans with each client within 30 days of client assignment. Care Plans must reflect the needs and desires of client as outlined in the Comprehensive Assessment. Care Plans are to be active and fluid documents that must be reviewed and updated on a regular basis. All interventions derive from the Care Plan.
4. Ensure that client's confidential health care and personal information is protected at all time. Responsible to ensure that appropriate consent forms are signed and updated as required. Ensure that exchanges of information are only disclosed to those individuals for whom you have signed consent. Responsible for the safeguarding of electronic devices and passwords.
5. Coordinate all needed and required services for clients, including, but not limited to, medical, substance use, mental health, and social support services. Work with the client toward independence and improved self management skills through the use of intervention methods including: Motivational Interviewing, role playing, modeling, and teach back. Accompany clients to appointments with service providers to ensure access to and understanding of services provided and required follow-up.
6. Responsible for the overall care coordination of assigned clients. Ensure that case conference activities with the client and their care team occurs on an on-going basis and that information, including the care plan, is shared and discussed with appropriate care team members. Ensure that appropriate program specific case conferencing documentation is completed.
7. Provide clinical case work interventions with assigned caseload.
8. Responsible to document all intervention conducted with the client or on their behalf in the appropriate program's platform and error free utilizing the Problem/Intervention/Follow-up (PIF) format. Track all intervention on the program specific Client Contact logs. Documentation is to be completed immediately following the intervention and program specific monthly monitoring data is to be submitted weekly and no later than the end of the month.
9. Independently travel between multiple off-site locations. Travel, as required, to community based meetings, provider sites, client's home and any other site to assist the client in meeting individual care plan goals.
10. Provide effective customer service as well as culturally and linguistically appropriate care to all customers (internal and external), clients, and patients.
11. Responsible to actively participate in the Department's Quality Improvement and Quality Assurance efforts as directed by their supervisor, including but not limited to participation on the Department's Quality Improvement Committee.

Qualifications

• Master's degree in social work from CSWE accredited school; Require LMSW or within 6 months of employment.
• Bilingual English / Spanish required
• Proficient computer skills
• Computer operations required
• At least TWO years experience in a health care setting, HIV/AIDS, alcohol/substance use and/or mental health program required
• Valid drivers license required
• Access to personal car for work related travel required
• Possesses well-developed and effective interpersonal skills and is able to communicate effectively verbally and in writing.
• Demonstrates confidence in actions and exercises good judgment.
• Displays leadership ability and the willingness to assume authority and accountability for the direction and supervision of others.
• Possess the ability to plan, organize, develop and implement goals, objectives, as well as policies and procedures necessary for quality care.
• Ability to embrace and adapt to change.
• Demonstrates ability to recognize problems, approach them in an objective manner, reach appropriate solutions, implement them, and evaluate for effectiveness.
• CASAC or Qualified Health Professional preferred