Schedule
Full Time, Day Shift (80 hours Biweekly)
Hours: Monday - Friday, 8:00am - 4:30pm (Varied based on case load)

General Summary

Collaborates with all members of the Special Programs team to plan and implement optimal and efficient care plans for medically and socially complex patients. This includes direct provision and/or assistance in the provision of social determinant of health (SDOH) barriers for patients referred to Special Programs.Plans, organizes, and implements care plans for patients and families supported by a multitude of social programs throughout WellSpan's footprint including: Transitional Housing, Medical Legal Partnership, Prison Re-Entry, and Bed Lease Programs. Works individually or in a team setting to identify patients requiring supports in addressing SDOH barriers prohibiting a positive health care journey.This position requires a broad-based knowledge of community resources, acute and community social planning for patients. Experience should include knowledge of the spectrum of health and social services across the continuum, available community resources, and patient benefit design are important components of the role.

Essential Functions:

Receives referrals from system case management teams for patients identified as having SDOH barriers inhibiting their health journey or access to care. Also receives patient referrals from community partners including but not limited to local shelters, prisons, nursing facilities, personal care homes, and social agencies. Conducts thorough review of patient electronic medical record to identify appropriate needs based on medical and social concerns. Provides education and resources for referring partner, advocates for patient self-determination and appropriate level of care, and matches patient needs with appropriate supportive Special Program(s). Utilizes Motivational Interviewing techniques as a patient-centered approach to identifying patient's appropriate placement in Special Program(s) based upon SDOH barriers. Maintain a caseload of patients according to department policies. Meet patients in a multitude of locations including but not limited: acute or community settings, primary care, or specialty offices, prison, shelters, personal care homes, and other locations as identified. Develop and implement care plans to maximize healthcare outcomes and facilitate wellness with periodic review and update according to department protocols. Perform patient outreach according to established protocols and document in electronic medical record. Documents patients' assessments, care plans, goals, and interventions in electronic medical management system according to department standards. Provide resource management to improve care, patient experience and reduce unnecessary cost and utilization: right care, right place, right time. Collaborate with Community partners, VNA, PCPs, Specialists, and others to effectively implement and carry out a patient-centered care plan., documents on the medical record in a timely fashion: psycho-social assessments, identified care plan, barriers, changes, and progress toward plan completion. Advocates on behalf of patients and families to gain access to services and resources. Refers patients to other providers, as necessary. Performs a variety of functions to address patient's psycho-social needs with referrals for counseling, community services, protective services, and financial assistance referrals, among others - and supports barriers to obtaining these services. Meets with collaborative community partners regularly to achieve program(s) success including but not limited to: nursing facilities, shelters, personal care homes, criminal justice agencies, law agencies, benefits coordinators, and Area Agencies on Aging. Identifies discharge plan by arranging for psycho-social, psychological, and practical assistance across the continuum of care. Actively engages the patient and/or family in the assessment, problem solving and referral process including transfer and discharge plans. Interacts with patients' broad interdisciplinary team in the development of the discharge plan addressing the patient's/family's psycho-social support. Assists patients and families in navigating the healthcare system, provides a warm hand off to post program supportive services, and tracks program outcomes to promote continuous program improvement.

Common Expectations:

Demonstrates knowledge of the principles of growth and development over the life span of assigned patient population by program. Assesses and interprets patient age specific data and provides appropriate, age specific treatment. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise. Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation. Prepares and presents utilization data analysis as required. Develops and initiates educational programs regarding utilization management principles.

Qualifications

Minimum Education:

Bachelors Degree In Health and human services field or social work. Required

Work Experience:

3 years Relevant experience. Required Social Work experience. Preferred

Licenses:

Licensed Social Worker Upon Hire Preferred or Licensed Clinical Social Worker Upon Hire Preferred

Driver's License Statement:

Must possess a valid driver's license in the current state of residence. Driving record must meet requirements established by WellSpan Risk Management.

Knowledge, Skills, and Abilities:

Excellent interpersonal/communications skills. Basic computer skills. Able to maintain confidentiality. Able to act in a professional manner. Maintains job competency.

Benefits Offered:

Comprehensive health benefits Flexible spending and health savings accounts Retirement savings plan Paid time off (PTO) Short-term disability Educational assistance Financial education and support, including DailyPay Wellness and Wellbeing programs Caregiver support via Weallthy Childcare referral service via Wellthy You’re unique and you belong here.

At WellSpan Health, we are committed to treating all applicants fairly and equitably, regardless of their job classification. If you require assistance or accommodation due to a disability, please reach out to us via email at . We will evaluate requests for accommodation on a case-by-case basis. Please note that we will only respond to inquiries related to reasonable accommodation from this email address. Rest assured, all requests for assistance or accommodation are handled confidentially, allowing applicants to share their needs openly and honestly with us.