For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us and help people live healthier lives while doing your life's best work.(sm) Our team is focused on achieving wellness for the most socially, medically, and behaviorally complex individuals with sensitivity to the impact of social determinants of health. Our commitment to innovation generates new ideas with a distinctive focus on driving impactful change and improved patient outcomes within the communities we serve. Discharge Social Worker: This role will help create and define a new standard of coordinated discharge care. Working collaboratively in a cross-functional team, the Discharge Care Coordinator will partner closely with the Discharge Care Manager Nurse. Together they will lead comprehensive care coordination for members while they are in the acute inpatient hospital setting and throughout the 30 days following an inpatient stay. With a focus on validated learning, the DCC will propose refinements to the care model and serve as a subject matter expert to inform and implement broader adaptations of the care model in adjacent communities and other locations nationally. Discharge care coordination entails working with the following roles: Discharge Care Manager Nurse, members, primary care providers, acute inpatient care managers and leadership, Medical Director team, Network team, alternate level of care teams, behavioral health advocates, facility discharge planners, ancillary providers, community health workers, and other internal and external member support programs. The Discharge Care Coordinator (DCC) acts as a resource for information about and referral to community based services. This is critical to ensuring the member has a safe discharge to home or other setting and to support readmission reduction in accordance with regulatory standards.Primary Responsibilities: By obtaining patient feedback, monitoring behavior and analyzing outcomes, the DC SW will play a pivotal role that improves individualized patient care. The Discharge Social Worker will help to coordinate and manage the discharge plan in close partnership with the Discharge Case Manager Nurse and other key clinical care team members. The DC SW is responsible for providing social work services to patients and families which includes educating the patient, family and members of the healthcare team regarding benefits, community resources, and referrals for counseling and other pertinent information. The DC SW will also be responsible for triaging referrals and collaborating on cases with other members of the healthcare delivery team. It is critical that the DC SW is able to assist the patient in a sensitive and supportive manner, while acting as an advocate on behalf of the patient. The DC SW will follow the member while in the acute inpatient setting and in the 30-day post discharge period. Responsibilities will include, but are not limited to:Works collaboratively with team members in a matrix environment to ensure an end to end positive experience for members, providers and care teams Assess patient and family psychosocial needs and develop plan of care in concert with patient, physicians, nurses and other members of the departmental team Participate in regular, cross-functional team meetings to share patient feedback and care model synthesis Assist in care model refinement embracing a collaborative build-measure-learn perspective of continuous improvement Provide insights and feedback to inform broader expansion of the discharge care coordination model Train and coach nursing staff to replicate and apply care model protocol and techniques Document patient / family status, diagnosis, treatment plan, goals, interventions, evaluation results, observations and progress in medical record Serve as patient advocate and liaison with physicians, families, insurance company, community agencies and others as needed to ensure continuity of care Assist in the evaluation of member discharge needs including delays in care and readmission prevention plan Coordination with the facility Discharge Planner to ensure post hospital services are arranged prior to the member being discharged Collaboration with providers and members to coordinate care, including onsite or telephonic visits in the inpatient setting and telephonic outreach in 30-day post discharge period Participate in rounds with the Medical Director to discuss cases as needed Assist with coordination of difficult cases needing placement in an alternate level of care facility Participate in team meetings, education discussions and related activities Other responsibilities as assigned
Required Qualifications:Licensed Masters prepared Social Worker or LCSW Licenses must be active and unrestricted in the State of Florida Current Florida resident and commutable distance to Orlando, Florida Ability to travel domestically up to 25% Demonstrated ability to build and maintain community resource repository Knowledge of Florida resources and community organizations Strong/Advanced experienced with Social Determinants and Health Disparities and serving this population Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others Ability to build and maintain relationships will be essential Proficiency in typing skills and software applications that include, but are not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint and Microsoft Outlook Demonstrated ability to assist with focusing activities toward a strategic direction as well as develop tactical plans, drive performance and achieve targets Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of actionPreferred Qualifications:Proficiency utilizing and charting in electronic medical records Previous experience in a hospital or medical setting Case management experience in Discharge planning or Transition Management Experience in managed care A working knowledge of the following; social work theory / practice, ability to utilize a variety of diagnostic tools / techniques including DSM V State and community based programs, including rules and regulations applicable to these programs Advanced directives, POLST and legal regulations, including but not limited to reporting of abuse Bilingual (Spanish and English)If the hired individual resides in Florida (office based or telecommuting) this position requires the AHCA Level II background check (fingerprinting) by the State of Florida for all clinicians that have direct face to face contact with members OR employees who will have access to confidential patient data and will require renewal every five years. Careers at UnitedHealthcare Community & State. Challenge brings out the best in us. It also attracts the best. That's why you'll find some of the most amazingly talented people in health care here. We serve the health care needs of low income adults and children with debilitating illnesses such as cardiovascular disease, diabetes, HIV/AIDS and high-risk pregnancy. Our holistic, outcomes-based approach considers social, behavioral, economic, physical and environmental factors. Join us. Work with proactive health care, community and government partners to heal health care and create positive change for those who need it most. This is the place to do your life's best work.(sm) Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. Job Keywords: Master's degree, discharge planning, acute care, managed care, Medicaid, Medicare, community health, LMSW, LCSW, social services, Orlando, FL, Florida, clinical, licensed social worker
Internal Number: 745769
About UnitedHealth Group
Our mission is to help people live healthier lives and to help make the health system work better for everyone.- We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve and their communities. - We work with health care professionals and other key partners to expand access to quality health care so people get the care they need at an affordable price. - We support the physician/patient relationship and empower people with the information, guidance and tools they need to make personal health choices and decisions.