Population Health & Concierge Care Coordination, Social Worker

Position Summary:


The Population Health Social Worker plays a crucial role in facilitating the psychosocial care of patients to ensure quality outcomes and appropriate utilization of healthcare resources. As a key member of a multi-disciplinary team, the Population Health Social Worker provides comprehensive care coordination services to high-risk enrollees by evaluating psychosocial and economic co-morbidities that impact health outcomes. This role involves participating in identification activities such as panel management, conducting bio/psycho/social assessments, offering patient education, providing behavior change counseling, and supporting other related activities for all lines of business. This includes serving elders and adults with disabilities who will require assistance to transition to Long-Term Services and Supports (LTSS), as well as adults and children with severe mental illness (SMI).

The Population Health Social Worker is responsible for assisting with the development and achievement of care plan goals, as well as providing linkages to community resources to support patients in managing their health and improving their quality of life. The role requires close collaboration with medical providers, care coordinators, and other healthcare professionals to address the complex needs of the population served. The Social Worker performs all duties and responsibilities in a courteous, customer-focused, and ethical manner, ensuring that patient care is delivered with the highest standards of professionalism and compassion.

This position is integral to the holistic management of patients' health, focusing on psychosocial interventions that complement medical care, promote patient engagement, and facilitate access to necessary resources and services, ultimately contributing to the overall improvement of patient outcomes and the efficient use of healthcare resources.

Essential Duties and Responsibilities:

Provide Psychosocial Support: Demonstrates the ability to provide psychosocial support and linkages to community resources for assigned patients, addressing their unique needs and barriers to care.

Care Plan Development and Monitoring: Participates in the development and ongoing monitoring of individualized care plans with the multi-disciplinary healthcare team, patients, and family/caregivers. Focuses on promoting patient strengths, advancing patient well-being, and assisting patients in achieving their health goals.

Assessment and Ongoing Evaluation: Conducts comprehensive assessments of patients' psychosocial functioning and needs, including evaluation of chronic illness impacts, social determinants, support systems, coping abilities, and prior functioning levels. Assesses patients' progress and adjusts the care plan as necessary throughout enrollment in the population health management program.

Standardized Post-Discharge Assessments:

Conduct comprehensive, standardized post-discharge assessments to ensure patients experience a safe and seamless transition of care, from inpatient care to their home or community setting, as well as to identify ongoing support needs, and comply with quality performance measures This assessment aim to:

• Evaluate Patient Stability: Assess the patient's physical, emotional, and psychosocial well-being post-discharge to identify any immediate risks or concerns.
• Identify Ongoing Support Needs: Determine the necessity for additional medical, behavioral health, or social support services, such as home health, transportation, medication management, or follow-up appointments.
• Ensure Medication Adherence and Understanding: Verify that patients understand their prescribed medications, including dosage, potential side effects, and the importance of adherence to prevent readmission.
• Assess Social Determinants of Health (SDOH): Identify barriers such as food insecurity, housing instability, or lack of caregiver support that may impact recovery and long-term health outcomes.
• Enhance Care Coordination: Facilitate communication between healthcare providers, case managers, and community organizations to align post-discharge care with the patient's needs and preferences.
• Monitor Readmission Risk: Use evidence-based screening tools to evaluate the risk of hospital readmission and implement necessary interventions to reduce avoidable readmissions.
• Improve Patient Education and Self-Management: Provide tailored guidance on managing chronic conditions, recognizing warning signs, and accessing available resources to promote patient independence.
• Ensure Compliance with Quality Performance Measures: Adhere to contractual and regulatory requirements by documenting assessment findings, follow-up actions, and patient outcomes in accordance with quality and accreditation standards.
• Facilitate Family and Caregiver Engagement: Engage family members or caregivers in the discharge planning process to ensure they have the necessary knowledge and resources to support the patient's recovery.
• Track and Report Outcomes: Collect and analyze post-discharge data to assess program effectiveness, identify gaps in care, and contribute to continuous quality improvement efforts.

Resource Mobilization and Intervention: Mobilizes appropriate resources, intervenes as necessary, and evaluates actions taken to achieve expected health goals. Collaborates with healthcare providers and other stakeholders to ensure comprehensive support for patients.

Consultation and Coordination: Provides consultation to Population Health Care Managers when coordination with significant or intensive community resources is necessary to achieve desired treatment outcomes. Collaborates with other disciplines to ensure comprehensive, patient-centered care.

Family Engagement and Support: Identifies the need for and conducts family meetings to facilitate informed decision-making and support patients and families in navigating complex health and social situations.

Medical Co-Management: Refers to and confers with appropriate medical professionals for the co-management of patients with complex medical and social needs, ensuring a holistic approach to care.

Care Coordination and Barrier Reduction: Formulates and implements appropriate plans of care that address barriers to healthcare access, aiming to prevent unnecessary hospital admissions and emergency room visits.

Interdisciplinary Collaboration: Actively participates in interdisciplinary Population Health staff meetings, contributing to collaborative care planning and problem-solving.

Documentation and Record-Keeping: Accurately documents assessments, care plans, interventions, and patient/family interactions in the enrollee database, ensuring all care actions are recorded in compliance with regulatory and organizational standards.

Resource Coordination: Coordinates with other disciplines to arrange or provide beneficial programs, therapies, or activities that support patients' self-management of their health, based on their psychosocial needs and age-specific considerations.

Community Resource Familiarity: Maintains an up-to-date directory of community resources and educates patients and families about the requirements and limitations of local, state, and federal programs relevant to their needs.

Patient Education: Provides education to patients and families on navigating healthcare systems, understanding their care plans, and accessing available resources to meet their health and social needs.

Collaboration and Emotional Support: Demonstrates the ability to collaboratively coordinate care with other healthcare disciplines, providing appropriate psychosocial and emotional support to patients and their families.

Regulatory Knowledge: Maintains current knowledge of managed care regulations, Medicaid/Social Security guidelines, and community agency programs to support compliance and inform care planning.

Performance Improvement Participation: Engages in continuous performance improvement reviews and contributes to quality improvement initiatives as assigned, identifying and reporting potential quality concerns according to corporate policy.

Professional Documentation: Demonstrates thorough documentation and updates for all referrals, counseling sessions, and interventions, ensuring compliance with legal and organizational standards.

Judgment and Critical Thinking: Utilizes professional judgment, critical thinking, and self-management techniques to assist patients in overcoming barriers to goal achievement and improving their overall health outcomes.

Quality Monitoring: Collaborates with the population health team to monitor practice and process improvements, ensuring effectiveness of workflow, service provision, and risk reduction.

Patient Advocacy: Advocates for patients by identifying gaps in care, addressing social determinants of health, and ensuring access to necessary resources to optimize patient outcomes.

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

Qualifications:

• Minimum of a Master's Degree in Social Work (MSW)

Certificates and Licenses:

• State Licensure - Must meet the state-specific licensure requirements for social workers
• LCSW Licensure in State of Florida (Preferred)
• Certified Case Manager (CCM) (Preferred)
• Certification in Population Health or Health Coaching (Preferred)

Experience:

1. Social Work Experience: minimum of 3-5 years related field
2. Experience in Managed Care/Health Plan Setting : 3-5 years of experience in a managed care, health plan, or insurance setting.
3. Experience with Utilization Management and Care Coordination : Experience coordinating care across medical, behavioral, and social service providers, including familiarity with utilization management processes, appeals, and authorizations.
4. Knowledge of Medicaid/Medicare Regulations : Experience working with Medicaid, Medicare, or other state and federal health care programs, including knowledge of relevant regulations and compliance requirements.
5. Knowledge of Microsoft Office and internet software
6. Knowledge of EPIC and/or JIVA (preferred)

Skills and Abilities:

• Exceptional Interpersonal Communication Skills : Demonstrated ability to collaborate and communicate effectively in a team setting, with a focus on building and maintaining professional relationships with enrollees and other members of the care team.
• Oral and Written Communication : Excellent oral and written communication skills, with strong problem-solving abilities. Proficiency in speaking effectively before groups of customers, employees, or other stakeholders within the organization.
• Self-Motivation and Independence : Ability to self-motivate and work independently with minimal supervision, demonstrating strong organizational, problem-solving, and decision-making skills.
• Analytical and Critical Thinking : Strong analytical skills and problem-solving ability, with a focus on reviewing clinical information, assessing needs, and developing tailored care plans to improve member outcomes.
• Proficient in Team Building and Collaboration : Experience in building and participating in cross-functional teams, with a strong ability to facilitate coordination, communication, and collaboration among care team members to achieve goals and maximize positive member outcomes.
• Project Management and Follow-Through : Ability to follow projects or assignments through to successful completion, ensuring tasks are executed effectively and within established timelines.
• Experience with Adult Learning Styles and Motivational Interviewing : Skilled in applying motivational interviewing techniques and understanding adult learning styles to educate and empower enrollees toward self-management and lifestyle changes.
• Compliance and Documentation : Proficient in maintaining documentation that meets compliance with quality standards, organizational policies, and HIPAA guidelines, including accurate and timely record-keeping.
• Cultural Competency and Sensitivity : Ability to work effectively with diverse populations, understanding the cultural, linguistic, and socioeconomic factors that impact care delivery and engagement.
• Proficiency with EHR and Health Plan Systems : Experience using Electronic Health Records (EHR) and health plan-specific systems, such as care management platforms or claims processing systems, to coordinate care and track member progress.
• Decisive Judgment and Professional Interaction : Strong professional interaction skills with the ability to make sound decisions, handle complex situations, and maintain a high standard of professionalism in all member and provider interactions.

Work Schedule:

Community Care Plan is currently following a hybrid work schedule. The company reserves the right to change the work schedules based on the company needs.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee must occasionally lift and/or move up to 15 pounds.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity and inclusion.

Background Screening Notice:
In compliance with Florida law, candidates selected for this position must complete a Level 2 background screening through the Florida Care Provider Background Screening Clearinghouse.

The Clearinghouse is a statewide system managed by the Agency for Health Care Administration (AHCA) and is designed to help protect children, seniors, and other vulnerable populations while streamlining the screening process for employers and applicants.

Additional information is available at:
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