- Consistently exhibits behavior and communication skills that reflect Tandigm Health’s commitment to the mission and values of the organization.
- Performs psychosocial evaluations of patient’s physical, social and emotional functioning, to include assessment of financial well-being and support systems.
- Assesses social determinants of health and works collaboratively with patient, family and care management team to address barriers.
- Provides crisis intervention to patients and families as needed.
- Demonstrates a strong understanding of available community resources.
- Provides community resource information to patients/families and performs referral and liaison activities as necessary.
- Develops a plan of care in collaboration with the care management team.
- Assists patients with the process of developing an Advance Care Plan.
- Assists patients and their families with transitions of care out of acute and post-acute care settings for patients with complex discharge needs.
- Documents assessments, plans and findings in appropriate technological platform within set standards of the organization.
- Participates as appropriate in weekly patient care rounds for patients.
- Participates on an assigned basis in educational training related to the psychosocial aspects of physical and emotional illness/disability.
- Acts as a resource to other Social Workers within the organization.
- Uses, protects, and discloses patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
Education and Experience
- Master’s degree in Social Work (MSW required) from an accredited school of social work education with a specialization in clinical practice; with:
- Three (3) years of related experience clinical or service coordination experience applicable to the managed care population; or
- One (1) or more years of experience working in a home-care role and experience with geriatric and/or end-of-life care with:
- Current, unrestricted Social Worker license in the State of Pennsylvania (LSW, LCSW, LBSW); and
- Basic Life Support for Healthcare providers (AHA) or CPR/AED for the Professional Rescuer (American Red Cross).
** Must also possess a PA State driver’s license and must be able to travel throughout the five territory (Bucks, Montgomery, Chester, Philadelphia & Delaware Counties) as well as travel to our West Conshohocken, PA corporate office for company and interdepartmental meetings as needed **.