The Advanced Care Planning Social Worker facilitates access to health and psychosocial services to improve overall health outcomes of members who have been identified as appropriate for Dean Health Plan (DHP) and Dean Medical Group (DMG) case and disease management programs, works with a multidisciplinary team to assist the member in reaching an optimal level of health and independence and develops relationships with members as an integral member of the healthcare team, and acts as a liaison and advocate between the member, family, providers, and community.
Essential Job Duties:
Identify member/family psychosocial, financial, or legal concerns which affect patient care management. Interact with the member, family, and interdisciplinary team to facilitate the patient care process.
Demonstrate clinical and social assessment skills, consistent with state licensure scope of practice requirements.
Assess member health status, socioeconomic needs, cultural beliefs, physical ability and condition-specific education needs and provide appropriate resources and referrals.
Improve member and/or family understanding of and adjustment to the medical diagnosis, to maximize the benefits of medical intervention, and to enhance member/family functioning throughout the course of care.
Provide short term emotional needs intervention counseling for member and/or family, as needed.
Identify and utilize appropriate community resources to optimize patient outcomes.
Provide liaison and referral services to medical specialists and community agencies.
Maintain HIPAA standards and confidentiality of protected health information.
Uphold professional ethics according to professional and corporate standards.
Plan and Conduct Advance Care Planning Group Sessions, including scheduling, coordination of resources, monitor attendance and feedback analysis.
Facilitate member/patients advance care planning conversations telephonically or in person.
Assist members/patients and families/significant others with completing Advanced Directives, Healthcare Power of Attorney or Declaration of Physicians (Living Will).
Provide timely updates to the member's care plan to ensure that goals are clearly outlined and that interventions are completed. Prioritize and target interventions, consistent with state licensure scope of practice requirements. Make appropriate recommendations to the care plan which support the overall treatment plan and the member's health goals.
Communicate and/or meet regularly with member's Primary Care Provider and assigned Case Manager to ensure that care gaps are closed and that barriers to access are eliminated.
Work in collaboration with Primary Care Physician, Case Manager, Case Management Specialist, and Pharmacist.
Maintain current knowledge of legal and regulatory changes affecting care delivery.
Maintain knowledge of medical and psychosocial practices, policies and protocols used in treatment of patients.
Knowledge of community and social resources (transportation, housing, and food).
Demonstrate skill in crisis, conflict, and stress management.
Assist with and participate in meeting company and department goals, such as quality improvement activities.
Act as a resource to the Care Management and Medical Affairs Division Staff. Work collaboratively and support the efforts of team members.
Promote timely and effective communication based on individual and/or situational requirements; utilize appropriate means to ensure adequate information flow.
Actively support compliance with NCQA and governmental requirements, as appropriate to the position.
Perform other duties as assigned, in an emergency or other operational situation for which the employee is qualified.
Master's Degree in Social Work
Active and unrestricted State of Wisconsin Social Work licensure.
Previous experience in a health care setting.
Ability to work independently, to handle multiple assignments, and to prioritize workload.
Ability to exercise independent and sound judgment in decision making, utilizing all relevant information.
Demonstrated high level time management, organizational skills, and priority setting.
Communicate effectively in person and by phone.
Advanced ability as a licensed professional to communicate verbally and in written format on any level required to meet the demands of the position, using lines of authority appropriately.
Ability to create, reviews, and interpret treatment plans.
Demonstrated negotiation skills.
Demonstrated effective communication methods and skills.
Intermediate knowledge and skill with MS Office, including Excel, Word and Outlook Express.
You’ve known us as many names throughout St. Louis, and now, we’re bringing our hospitals, doctors, home care and other services together under one name – SSM Health. With seven hospitals, 350+ physicians, more than 40 physician locations and 12,000 employees, we are part of something bigger and better. We’re connected to a wealth of resources, expertise and advance technology to help you, your fa...mily and our community live long, healthy lives.
We’ve grown and changed a lot over our 143-year history. Our name may be changing but our mission remains the same