Social Worker, LSW- 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 patients 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 members 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 Jeffersons 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

Work Shift

Worker Sub Type

Employee Entity

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 65000 people strong dedicated to providing the highest-quality compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrows 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 8300 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.

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues including medical (including prescription) supplemental insurance dental vision life and AD&D insurance short- and long-term disability flexible spending accounts retirement plans tuition assistance as well as voluntary benefits which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues including those who work less than part-time(including per diemcolleagues adjunct faculty and Jeff Temps) have access to medical (including prescription) insurance.

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