The Population Health Social Care Supervisor will:

• This position will have oversight and project management responsibilities for community-based initiatives.

• Experience working with underserved and diverse populations in community settings .

• Develops and monitors Social Care team goals; provides ongoing feedback and coaching; conducts annual performance reviews; routinely evaluates staffs skills and technical comprehension

• Contributes to the growth and success of their team and CHW program and its goals.

• Active participation in CHW forums and community-based initiatives.

• Analyzes processes and procedures to develop innovative approaches to challenges or issues.

• Attend and actively participate in all project related trainings and project meetings.

• Strive for high customer satisfaction by providing prompt solution-focused support to team co-workers patients and community partners.

• Ensures an atmosphere of open communication teamwork and empowerment to make informed decisions.

• Collaborates with Senior Manager of Population Health Transformation in analyzing reviews metric data and chart audits and uses that information to identify opportunities for improvement.

• Collaborates with Senior Manager of Population Health Transformation on overall budget for Care Management.

• Oversees Social Care Team position control and hiring of new staff.

• Contributes to the clinical quality and financial outcomes of the Population Health Department.

• Familiarity with value-based payment models and supports payor related value-based care programs.

• Performs all other related duties as assigned by Senior Manager of Population Health Transformation.

• Demonstrates a measurable organized enthusiastic and outcomes-oriented approach.

The Social Care Team is responsible for supporting and coaching at-risk patients to manage their own health and assisting them in navigating the health care and social service systems.

• Reliable and accessible transportation along with current insurance coverage is .

• Complete all required documentation and data tracking in a detailed and timely manner.

• Complete all telephone and face-to-face contacts with patients in a timely and professional manner.

• Complete enrollment forms and other needed documentation and documents in approved format in a timely manner.

• Assist patients in the community through home visits attending medical appointments and accessing other community-based resources.

• Assist patients in the community through home visits attending medical appointments and accessing other community-based resources.

• Must have the ability to relate to diverse groups of people and people on all levels.

• Provide support and education to patients to assist them in adhering to medical recommendations and taking medications as prescribed.

• Assist patients in scheduling medical and social service appointments and attending appointments as needed or requested.

• Assist patient in securing transportation to medical and social service appointments.

• Provide assistance with medical and behavioral health referrals to ensure client access and follow-through.

• Assist patients in obtaining necessary medications through patient assistance programs and other reduced cost programs.

• Complete client-centered treatment goals in collaboration with patients and review progress in meeting goals routinely and at identified 60-day check-in times.

• Provide regular and timely updates to medical providers referral sources and assigned clinics on patients progress to meet treatment goals and to trouble shoot any problems or concerns.

• Review referral forms needs assessments or Electronic Medical Record data and determine appropriateness of referrals. For patients not appropriate for projects provide active referrals to other community resources.

• Assist clients in accessing and understanding necessary health and wellness information provided by their medical provider and clinic.

• Ensure clients access to interpreters and translators for medical and social service appointments.