Social Worker MSW Population Health

Job Details

Job Description

Essential Functions
* Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.
* Integrates evidence based practice, clinical expertise, patients, their family/designated care partner(s) preferences and cultural beliefs and values for delivery of optimal health care.
Partners with patients, their family/designated care partner(s) in identifying learning needs and priorities and provides education in ways that is useful, understandable and affirming.
* Conducts psychosocial assessment/reassignment of patients/significant others relating to the social, emotional and cognitive capabilities of patients in relationship to their illness and health maintenance needs.
* Develops and implements a plan of intervention that addresses identified needs related to needs/problems identified during assessment.
* Compiles and discusses findings with support team to evaluate and manage geriatric conditions in the home.
* Performs psychosocial assessments that will identify applicable barriers, problems, goals, and interventions that will close gaps in care and address those needs and improve or maintain the health status of the patient, based on assessment of patient's needs and environment
* Engages and counsels patient and family members to develop an individualized plan of care to promote healthy lifestyles, close gaps in care, and reduce unnecessary ER utilization and hospital readmissions. Develops and coordinate the individualized plan of care with the member, member's family, providers and community agencies as applicable. Involves other staff to support the individualized plan of care based on identified needs of the patient
* Follow-ups with the patient according to established clinical program protocols and timeframes to monitor their status, evaluate the effectiveness of the individualized plan of care, and identify new needs. Modifies the individualized plan of care or case status based on the status of the patient.
* Documents activities in a timely and accurate manner; assuring all documentation complies with Jefferson's quality standards, CMS standards, DVACO standards, etc.
* Provides counseling for patient/family/significant others to assist with coping with new diagnoses, chronic illness and palliative or terminal care
* Advocates for the patient and family throughout the entire episode of care. Functions as a resource to facilitate communication among the healthcare team and patient/family. Acts as a resource to patients and families to obtain necessary services
* Provides counseling and crisis intervention in cases involving child abuse/neglect, domestic violence, elder abuse, and institutional abuse. Provides interventions in cases regarding guardianship, mental health placement, advance directives, trauma, and substance abuse.

Competencies (Knowledge, Skills, and Abilities Required):
Knowledge of: Medical terminology and disease process; Community resources; Insurance regulations and requirements
Skill in: Work with multidisciplinary teams, outside resources, patients/families/significant others
Ability to: Establish an appropriate plan to safely discharge patients to the next level of care

Minimum Education and Experience Requirements:

Education:
Graduate from an accredited Masters of Social Work program required.

AND

Experience:
* 5 years' experience in hospital or community clinic, home care, discharge planning, and/or case management required
* 3 years' experience in a managed care environment preferred
* Minimum 2 years' experience working with frail or elderly population
* Strong behavioral health background

Minimum Certifications, Registration or License Requirements:
Active LSW or LCSW preferred

Work Shift

Worker Sub Type

Primary Location Address

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.

Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.