Social Worker

Position Overview: Describes the overall purpose of the position or why the position exists

The Social Worker assists patients and their families in navigating and gaining access to community resources, including services for mental health crisis, substance use, psychiatric, social, financial, educational, and other services appropriate for the patient’s need. The Social Worker supports patients through an integrated approach to care management, addresses social determinants of health (SDOH), and influences behavior changes resulting in improved well-being for the patient.

Essential Duties and Responsibilities: The following description is a general representation of the essential duties and responsibilities of the position.

• Assess patient’s unmet needs and provide social work specific care coordination and linkage to appropriate services to enhance patient health and well-being, increase patient satisfaction, and reduce health care costs. Partner with other care coordination, clinical, and support staff to identify and meet patient needs.
• Track referrals for patient compliance and assist in reducing any barriers patients may face in receiving needed services. Advocate for patients as needed to gain access to identified services.
• Maintain regular contact with patients, service providers, and programs involved with patient care to proactively identify and resolve issues and barriers.
• Support with identifying, developing, and maintaining new and existing community partnerships, informal support systems, and community building opportunities to help patients access additional support systems. Provide consultation to Medical, Behavioral Health, and other team members as needed.
• Provide complete documentation and reporting on patient services, in accordance with organizational requirements.
• Collaborate with the Patient, family/caregiver(s), and Providers to develop plan of care and health goals. Monitor adherence to care plans, evaluate effectiveness, monitor patient progress, and facilitate change through solutions focused interventions and Motivational Interviewing techniques as needed.
• Remain knowledgeable of patient’s health insurance status. Connect patient to additional resources when needed.
• Respond to behavioral health crisis presentations that occur over the phone and in clinic as directed.
• Ensure compliance and quality of Social Work Services through adherence to applicable policies and procedures.
• Other duties as assigned.