Qualifications: Licensed Master of Social Work (Clinical). Must attain MCBAP certification within 3 years of employment and complete other required training. Two years of social work experience with adult and pediatric populations in primary care/ambulatory care, home health agency, skilled nursing facility, school environment or similar setting. Knowledge of health and chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education. General computer knowledge and capability to use computers and internet.
Essential Functions: Provide direct social work and substance abuse counseling services to individuals and groups including screening, assessment, individualized treatment planning, and discharge planning. Maintains 100% of time devoted to direct patient care or related activities. Enrolls and maintains active provider status with such insurances as Medicare, Medicaid health plans and others. Completes an assessment of the client's needs, forming an accurate mental health diagnosis according to DSM4/5 develops appropriate clinical goals and provides treatment to reach goals. Providing all proper documents for clinical services including assessments, treatment planning, and progress notes and billing encounters in a timely manner. Establishing and maintaining a highly productive caseload.
Key Responsibilities:
- Identifies the targeted high risk and referred population within practice sites per PCP referral, electronic registry use, risk stratification, and patient lists. Includes patients with social and/or health crises.
- Assesses over time the mental health, educational, and psychosocial needs of the patient/family. Uses standardized assessment and screening tools such as depression screening, functionality, and health risk assessment.
- Collaborates with PCP, psychiatrist, patient, and members of the health care team, including continuum of care settings and community. Responsible for collaborating in the development of a comprehensive individualized plan of care and targeted interventions. Continually monitors patient/family response to plan of care and revises the care plan as indicated.
- Completes patient self-management support with a focus on empowering the patient/family to build capacity for self-care.
- Implement systems of care that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute episodes.
- Implements clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
- Coordinates patient care through ongoing collaboration with PCP, patient/family, community, and other members of the health care team. Fosters a team approach and includes patient/family as active members of the team. Takes the lead in ensuring the continuity of care which extends beyond the practice boundaries. Serves as liaison to acute care hospitals, specialists, and post-acute care services.
- Demonstrates excellent written, verbal, and listening communication skills, positive relationship building skills, and critical analysis skills.
- Reviews the current literature regarding effective engagement and communication strategies, counseling, care management strategies, and behavior change strategies and incorporates them into clinical practice.
- Maintains required documentation for all treatment and care management activities via the use of a paper and web-based data entry system. Completes all documentation necessary to allow for billing of services.
- Works with practice and to continuously evaluate processes, identify problems, and propose/develop process improvement strategies to enhance the delivery of care models.
- Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care and mental health team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.
Skills and Abilities:
- Knowledge of moderately complex clinical procedures.
- Must be computer proficient.
- Communicates in writing and orally, in person and through electronic means with proficiency and able to effectively explain complex and technical information to others.
- Demonstrate HIPAA confidentiality and privacy at work and off duty.
- Demonstrates customer focused interpersonal skills to interact in an effective manner with patients, practitioners, and families with diverse options, values, and religious and cultural ideals.
- Demonstrates critical thinking while managing clinical issues and utilizing assessment skills protocols.
- Demonstrates ability to function effectively in a fast-paced, fluid, dynamic, and rapidly developing environment.
- Excellent assessment and triage skills.
- Demonstrates ability to work collaboratively as an effective part of a Team Based Health Care organization as well as independently and be directly accountable for practice.
- Demonstrates time management, listening skills, problem solving, priority setting, and work organization.
