Fallon Health Weinberg is a partnership between Fallon Health of Massachusetts and Weinberg Campus of Erie County, New York. Fallon Health Weinberg offers a Program of All Inclusive Care for the Elderly (PACE) to serve the health needs of dual-eligible residents of the Western New York counties of Erie and Niagara.
Fallon Health is a company that cares. We prioritize our members--always-making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, we deliver equitable, high-quality coordinated care and are continually rated among the nation’s top health plans for member experience, service, and clinical quality. Weinberg Campus has been providing needed services to the elderly for more than 100 years, through both community-based programs and nursing facility care. It is a renowned geriatric education and training institution offering the widest range of housing and care options available on one campus.
At Fallon Health Weinberg, we believe our individual differences, life experiences, knowledge, self-expression and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status and other characteristics that make people unique.
The Social Worker provides services to members as referred by Nurse Case Managers and/or Navigators. The Social Worker assesses member needs, services and resources to address social, health, or economic needs of FHW members. This position assists the Enrollee and/or family in utilizing FHW benefits and/or community resources; develops a plan to coordinate a continuum of care consistent with the Enrollee’s health care needs and goals; and is able to utilize knowledge of benefit plan design, eligibility and/or financing alternatives that are available within the community to ensure Enrollees’ needs are met. The Social Worker is able to identify services, care delivery settings, and funding arrangements and recommends alternatives where appropriate.
The Social worker is an active participant in the Members Primary Care Team (ICT) and will participate in the ICT providing input and guidance to resources, services, social dynamics and needs of assigned members.
The Social worker utilizes varied interviewing techniques including but not limited to motivational interviewing, and employs culturally sensitive strategies to engage and work with members. The Social worker may visit the members in the home and long-term care setting to assess needs and monitor progress towards patient agreed upon goals.
Responsibilities Working directly with the ICT to assess the needs of Enrollees and assisting in the development of customized, proactive care plans resulting in the Enrollee attaining and/or maintaining an optimal functional status.Ensuring timeliness in the coordination and receipt of community services in compliance with documented care plan goals and objectives.Following Department and regulatory standards, seeks supplemental benefits and/or community services, as appropriate, to meet an Enrollee’s needs regarding: housing, food, clothing, transportation, financial assistance and other social supports.Identifies, aligns, and utilizes health plan and community resources that impact high-risk/high cost care.Creates contingency plans for each step of the process to anticipate treatment and service complications, while ensuring that the Member attains pre-determined outcomes.Streamlines the focus of the Member’s healthcare needs utilizing the most optimal treatment approach, promoting timely provision of care, enhancing quality of life, and promoting cost-effectiveness of care.Works collaboratively and cohesively with all members of the Primary Care. Utilizes a successful communication style and methods to engage Member’s in care management – does not ‘easily give up’ and works to engage Member’s as appropriate. QualificationsGraduate from an accredited school of social work – Master’s degree required, LMSW a plus
Valid and unrestricted license to practice social work in the state of New York;
Certification in Case Management desired, encouraged upon hire
reliable transportation required
A minimum of three to five years’ clinical experience as a Social worker with demonstrated experience working with the chronically ill, geriatric patients. Experience in Home Health/community setting, working with Medicare/Medicaid preferred. Experience working with patients in Long term care setting a plus. Background with disabled or behavioral populations preferred.
Familiarity with provisions of governmental and accrediting agency health plan requirements.
Strong demonstrated knowledge of Medicaid requirements to include impoverishment, trusts, requirements of medicare advantage programs and Managed Long term care.
Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
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