Social Worker – Central & Upper Bucks County

The Social Worker is responsible for clinical evaluation and management of patients either telephonically or in a home setting, as referred by the Primary Care Physician, Tandigm House Calls Clinician, or Tandigm Registered Nurse. The Social Worker provides care to patients/families to assist with access to community, financial and psychosocial resources. The Social Worker collaborates with other members of the health care team to develop a plan of care designed to move patients toward optimal health. The Social Worker utilizes expert knowledge of community resources and telephonic/face-to-face assessment and screening to evaluate the impact of any social determinants of health and engage patients/families while coordinating services to best address the plan of care. The Social Worker facilitates therapeutic interventions to assist patients with serious illnesses, providing counseling and crisis intervention, and assisting patients with the development of an Advance Care Plan when appropriate.

Essential Functions

  • 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:

Minimum:

  • Three (3) years of related experience clinical or service coordination experience applicable to the managed care population; or

Preferred:

  • One (1) or more years of experience working in a home-care role and experience with geriatric and/or end-of-life care with:

Certifications/Licenses

  • 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 **.

 

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