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Department

* This is a hybrid role with a weekly in-office requirement.

Job Summary

Under general supervision the Health Plan Social Work Care Coordinator (SWCC) is responsible for facilitating and coordinating the care delivered to an assigned group of members using multidisciplinary and member/family collaboration to ensure quality and cost effective outcomes are delivered within appropriate care coordination parameters. Coordination involves assessment of care needs planning support and evaluation of member care and related outcomes. Activities to be performed are screening and assessment of medical behavioral health and social determinants needs and gaps in care collaboration with the Member to develop a care plan with SMART goals scheduled outreach to support member in achieving their goals and supporting the Members self-efficacy to navigate systems. SWCC communicates closely with the Members care team inclusive of: the Member designated health representatives primary care provider behavioral health providers and other care coordinators involved with the Members care. Encounters occur face to face telephonically and electronically with members in clinic and in other community-based settings.

Position is an active contributor in the development of systems (e.g. work flows clinical pathways assessments) to improve the care of assigned member populations. Helps ensure compliance with state federal and third party payor requirements.


Essential Functions:

• Utilizes Care Coordination Processes:
  Systematically collects focused data relating health needs and concerns of member group or population.
  Establishes and maintains member-centered relationships.
  Analyzes assessment data to determine opportunities for health promotion health maintenance or health related problem needs and statements.
  Identifies and executes evidence-based interventions to support the Member in achieving their health goals.
  Identifies and works towards expected outcomes in a plan of care individualized for a specific member group or population.
  In collaboration with the Member develops a care plan that identifies strategies and alternatives to attain expected outcomes. Utilizes competent evidence based telephone encounters and electronic communications according to regulatory requirements and standards as well organizational policies and procedures.
  Conducts systematic evaluation of outcomes of care coordination in relation to structures and processes prescribed by plan.
  Documents in readable understandable language according to professional regulatory and agency standards.
  Documents and disseminates results of care to member caregivers and others involved in the care or situation as appropriate in accordance with contractual requirements state and federal laws regulatory requirements and Denver Health policy.
  (25%)
• Provide Care Coordination Services:
  Coordinates the delivery of care within the clinic setting throughout the organization and across health care settings.
  Provides relevant information across the care system within Denver Health and with other healthcare systems and payers when member care is transferred between and among different specialties and/or within one or more organizations.
  Provides information to the health care team including the member family and caregiver regarding available resources and benefits for health care services that ensures member choice and safe timely transition.
  Serves as point of contact within and among healthcare services and organizations.
  Coordinates community resources.
  Assures designation of primary responsibility among team members for each aspect of care plan avoiding duplication and fragmentation.
  Facilitates continuity of care using the multidisciplinary collaboration and coordination of all appropriate healthcare services and community resources across the care continuum.
  Orients member/caregiver to health care delivery system services access and resources. (25%)
• Health Teaching and Promotion:
  Identifies barriers to goals and strategies to address.
  Provides personalized education for optimal wellness.
  Encourages preventative care such as immunizations and cancer screening.
  Promotes appropriate utilization of resources.
  Assists and educates caregiver when member is unable to participate.
  Incorporates therapeutic communication health literacy cultural and linguistic needs and preference into education and goals.
  Supports members and caregivers in developing skills for self-efficacy to promote maintain or restore health such as healthy lifestyle tips risk-reducing behaviors age and developmental needs daily living activities and preventative care. (25%)
• Care Coordination:
  Responsible for a defined caseload of Members enrolled in the DHMP Medicaid Choice who are identified as having a medium or low risk acuity level using data from a variety of sources including the Member their caregivers providers administrative claims data pharmacy data and other inputs.
  Obtains Member consent to participate in the program as well as to share clinical information with the Members care team.
  Works collaboratively with the Member to set SMART (specific measurable attainable realistic and time-limited) goals and to graduate the Member to lower-intensity care programs and self-care within reasonable timeframes.
  Works under the supervision and advice of the Supervisor who can provide insight into medical conditions treatments medications and answer medically-related questions as needed. (25%)

Education:

• Masters Degree Social Work required

Work Experience:

• Three years of direct member care experience in acute ambulatory care or community-based care required

Licenses:
Knowledge Skills and Abilities:

• Bilingual in English/Spanish preferred not required.
• Knowledge of emotional and social factors that impact patients health.

Shift

Work Type

Salary

Benefits

At Denver Health we take care of the people who take care of our community. Our benefits are built to support your life your family and your future with generous paid time off fully paid parental leave exceptional retirement contributions comprehensive health coverage and nationally recognized well-being programs. We invest in your growth through tuition assistance career advancement pathways and professional development while also offering meaningful financial advantages through loan forgiveness eligibility and employer contributions. When you join Denver Health youre joining a mission-driven organization that invests in you.

Here is a small list of our benefit programs:

• Paid time off starting at 28 days per year inclusive of vacation personal/sick and 7 Holidays

• 100% paid parental leave up to 6 weeks

• Immediate eligibility for retirement plans with employer contribution up to 9.5%

• Generous medical dental vision plans in addition to employer paid disability and life insurance.

• Comprehensive well-being programs including on-site employee fitness center located on Denver Health main campus and nationally recognized RESTORE Center

• Free RTD EcoPass (public transportation)

• Childcare discount programs & exclusive perks on large brands travel and more

• Tuition reimbursement & assistance

• Education coaching and professional development opportunities through the Workforce Development Center (WFDC) that support internal career growth and advancement pathways

• Professional clinical advancement program & shared governance

• Public Service Loan Forgiveness (PSLF) eligible employer free student loan coaching and assistance navigating the PSLF program

• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer

About Denver Health

Denver Health is an integrated high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center a 555-bed acute care medical center Denvers 911 emergency medical response system 10 family health centers 19 school-based health centers Rocky Mountain Poison & Drug Safety the Public Health Institute at Denver Health Denver Health Medical Plan and Denver Health Foundation.

As Colorados primary and essential safety-net health care system Denver Health is a mission-driven organization that has provided millions in uncompensated care for the uninsured each year.

Located near downtown Denver Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.

Denver Health is an equal opportunity employer (EOE). We value the unique ideas talents and contributions reflective of the needs of our community. All job applicants for safety-sensitive positions must pass a pre-employment drug test once a conditional offer of employment has been made. Applicants will be considered until the position is filled.