Position Summary
The Population Health Social Worker plays a crucial role in facilitating the psychosocial care of patients to ensure quality outcomes and appropriate utilization of healthcare resources. As a key member of a multi-disciplinary team, the Population Health Social Worker provides comprehensive care coordination services to high-risk enrollees by evaluating psychosocial and economic co-morbidities that impact health outcomes. This role involves participating in identification activities such as panel management, conducting bio/psycho/social assessments, offering patient education, providing behavior change counseling, and supporting other related activities for all lines of business. This includes serving elders and adults with disabilities who will require assistance to transition to Long-Term Services and Supports (LTSS), as well as adults and children with severe mental illness (SMI).
The Population Health Social Worker is responsible for assisting with the development and achievement of care plan goals, as well as providing linkages to community resources to support patients in managing their health and improving their quality of life. The role requires close collaboration with medical providers, care coordinators, and other healthcare professionals to address the complex needs of the population served. The Social Worker performs all duties and responsibilities in a courteous, customer-focused, and ethical manner, ensuring that patient care is delivered with the highest standards of professionalism and compassion.
This position is integral to the holistic management of patients' health, focusing on psychosocial interventions that complement medical care, promote patient engagement, and facilitate access to necessary resources and services, ultimately contributing to the overall improvement of patient outcomes and the efficient use of healthcare resources.
Essential
Duties: and Responsibilities:
1. Provide Psychosocial Support
- Demonstrates the ability to provide psychosocial support and linkages to community resources for assigned patients, addressing their unique needs and barriers to care. 2.
- Care
- Plan
- Development and
- Monitoring: Participates in the development and ongoing monitoring of individualized care plans with the multi-disciplinary healthcare team, patients, and family/caregivers. Focuses on promoting patient strengths, advancing patient well-being, and assisting patients in achieving their health goals. 3.
- Assessment and
- Ongoing
- Evaluation: Conducts comprehensive assessments of patients' psychosocial functioning and needs, including evaluation of chronic illness impacts, social determinants, support systems, coping abilities, and prior functioning levels. Assesses patients' progress and adjusts the care plan as necessary throughout enrollment in the population health management program. 4.
- Resource
- Mobilization and
- Intervention: Mobilizes appropriate resources, intervene as necessary, and evaluates actions taken to achieve expected health goals. Collaborates with healthcare providers and other stakeholders to ensure comprehensive support for patients. 5.
- Consultation and
- Coordination: Provides consultation to Population Health Care Managers when coordination with significant or intensive community resources is necessary to achieve desired treatment outcomes. Collaborates with other disciplines to ensure comprehensive, patient-centered care. 6.
- Family
- Engagement and
- Support: Identifies the need for and conducts family meetings to facilitate informed decision-making and support patients and families in navigating complex health and social situations. 7.
- Medical
- Co-Management: Refers to and confers with appropriate medical professionals for the co-management of patients with complex medical and social needs, ensuring a holistic approach to care. 8.
- Care
- Coordination and
- Barrier
- Reduction: Formulates and implements appropriate plans of care that address barriers to healthcare access, aiming to prevent unnecessary hospital admissions and emergency room visits. 9.
- Interdisciplinary
- Collaboration: Actively participates in interdisciplinary Population Health staff meetings, contributing to collaborative care planning and problem-solving. 10.
- Documentation and
- Record-Keeping: Accurately documents assessments, care plans, interventions, and patient/family interactions in the enrollee database, ensuring all care actions are recorded in compliance with regulatory and organizational standards. 11.
- Resource
- Coordination: Coordinates with other disciplines to arrange or provide beneficial programs, therapies, or activities that support patients' self-management of their health, based on their psychosocial needs and age-specific considerations. 12.
- Community
- Resource
- Familiarity: Maintains an up-to-date directory of community resources and educates patients and families about the requirements and limitations of local, state, and federal programs relevant to their needs. 13.
- Patient
- Education: Provides education to patients and families on navigating healthcare systems, understanding their care plans, and accessing available resources to meet their health and social needs. 14.
- Collaboration and
- Emotional
- Support: Demonstrates the ability to collaboratively coordinate care with other healthcare disciplines, providing appropriate psychosocial and emotional support to patients and their families. 15.
- Regulatory
- Knowledge: Maintains current knowledge of managed care regulations, Medicaid/Social Security guidelines, and community agency programs to support compliance and inform care planning. 16.
- Performance
- Improvement
- Participation: Engages in continuous performance improvement reviews and contributes to quality improvement initiatives as assigned, identifying and reporting potential quality concerns according to corporate policy. 17.
- Professional
- Documentation: Demonstrates thorough documentation and updates for all referrals, counseling sessions, and interventions, ensuring compliance with legal and organizational standards. 18.
- Judgment and
- Critical
- Thinking: Utilizes professional judgment, critical thinking, and self-management techniques to assist patients in overcoming barriers to goal achievement and improving their overall health outcomes. 19.
- Quality
- Monitoring: Collaborates with the population health team to monitor practice and process improvements, ensuring effectiveness of workflow, service provision, and risk reduction. 20.
- Patient
- Advocacy: Advocates for patients by identifying gaps in care, addressing social determinants of health, and ensuring access to necessary resources to optimize patient outcomes.
This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.
Qualifications
• Minimum of a Master’s Degree in Social Work (MSW)
Certificates and Licenses
- State Licensure - Must meet the state-specific licensure requirements for social workers
- Certified Case Manager (CCM) (Preferred)
- Certification in Population Health or Health Coaching (Preferred)
Experience
- Social
- Work
- Experience: minimum of 3-5 years related field
- Experience in
- Managed
- Care/Health
- Plan
- Setting: 3-5 years of experience in a managed care, health plan, or insurance setting.
- Experience with
- Utilization
- Management and
- Care
- Coordination: Experience coordinating care across medical, behavioral, and social service providers, including familiarity with utilization management processes, appeals, and authorizations.
- Knowledge of
- Medicaid/Medicare
- Regulations: Experience working with Medicaid, Medicare, or other state and federal health care programs, including knowledge of relevant regulations and compliance requirements.
- Knowledge of Microsoft Office and internet software
- Knowledge of EPIC and/or JIVA (preferred)
Skills and Abilities
- Exceptional
- Interpersonal
- Communication
- Skills: Demonstrated ability to collaborate and communicate effectively in a team setting, with a focus on building and maintaining professional relationships with enrollees and other members of the care team.
- Oral and
- Written
- Communication: Excellent oral and written communication skills, with strong problem-solving abilities. Proficiency in speaking effectively before groups of customers, employees, or other stakeholders within the organization.
- Self-Motivation and
- Independence: Ability to self-motivate and work independently with minimal supervision, demonstrating strong organizational, problem-solving, and decision-making skills.
- Analytical and
- Critical
- Thinking: Strong analytical skills and problem-solving ability, with a focus on reviewing clinical information, assessing needs, and developing tailored care plans to improve member outcomes.
- Proficient in
- Team
- Building and
- Collaboration: Experience in building and participating in cross-functional teams, with a strong ability to facilitate coordination, communication, and collaboration among care team members to achieve goals and maximize positive member outcomes.
- Project
- Management and
- Follow-Through: Ability to follow projects or assignments through to successful completion, ensuring tasks are executed effectively and within established timelines.
- Experience with
- Adult
- Learning
- Styles and
- Motivational
- Interviewing: Skilled in applying motivational interviewing techniques and understanding adult learning styles to educate and empower enrollees toward self-management and lifestyle changes.
- Compliance and
- Documentation: Proficient in maintaining documentation that meets compliance with quality standards, organizational policies, and HIPAA guidelines, including accurate and timely record-keeping.
- Cultural
- Competency and
- Sensitivity: Ability to work effectively with diverse populations, understanding the cultural, linguistic, and socioeconomic factors that impact care delivery and engagement.
- Proficiency with
- EHR and
- Health
- Plan
- Systems: Experience using Electronic Health Records (EHR) and health plan-specific systems, such as care management platforms or claims processing systems, to coordinate care and track member progress.
Work Schedule
Community Care Plan is currently following a hybrid work schedule. The company reserves the right to change the work schedules based on the company needs.
Physical Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
A reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear.
The employee is frequently required to stand, walk, and sit.
The employee may occasionally be required to stoop, kneel, crouch or crawl.
The employee may occasionally lift and/or move up to 15 pounds.
Work Environment
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic travel. A reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.
We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion.
Background Screening Notice
In compliance with Florida law, candidates selected for this position must complete a Level 2 background screening through the Florida Care Provider Background Screening Clearinghouse.
The Clearinghouse is a statewide system managed by the Agency for Health Care Administration (AHCA) and is designed to help protect children, seniors, and other vulnerable populations while streamlining the screening process for employers and applicants.
Additional Information
is available at: 🔗 https://info.flclearinghouse.com [https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Finfo.flclearinghouse.com%2F&data=05%7C02%7CJake.Shanahan%40ahca.myflorida.com%7C4b82b03a51ad4f4b95a108de4232c2f0%7C583c5f193b644cedb59ee8649bdc4aa6%7C0%7C0%7C639020982980038846%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=xZdgpZEJ7lRUp18fRP71qweuFp0i1gIxOp6MWfK8zlM%3D&reserved=0]
