- Consistently exhibits behavior and communication skills that demonstrate Tandigm Health’s commitment to superior customer service, including quality, care, and concern for all internal and external customers.
- Conducts relevant patient assessments, the results of which are shared as social work consultations with the Nurse Care Manager, who is responsible for developing and overseeing complex care plans for high risk patients in the CCM program.
- Performs assessments of the patient’s physical, psychosocial, cognitive and emotional functioning, to include assessment of financial well-being and support systems.
- Assesses and evaluates social determinants of health and works collaboratively with the patient, their family, and other CCM members to identify and address existing barriers.
- Coordinates with the Nurse Care Manager and other CCM members (e.g., Field-Based Nurse, Nurse Practitioner, BH Specialist, Spiritual Counselor, Pharmacist) to ensure all factors impacting the patient’s well-being are being addressed through the care plan.
- Partners with other members of CCM to co-manage, coordinate, and deliver their respective elements of the patient care plans.
- Participates in multidisciplinary patient care rounds, as appropriate.
- Serves as a point of contact for patients and families for social elements of the care plan, including referral and liaison activities.
- Provides crisis intervention to patients and families.
- Promotes patient self-management strategies for improving health outcomes.
- Assists patients with developing an Advance Care Plan.
- Assists patients with complex discharge needs, and their families, with transitions of care out of acute and post-acute care settings.
- Uses, protects, and discloses patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
- Performs additional duties, as assigned.
Education & Experience
- Master of Social Work degree from an accredited school of social work education with specialization in clinical practice, with;
- Minimum 3 years of related clinical or service coordination experience, appropriate to the managed care population, is required
- Minimum 1 year of experience working in a home care role
- Experience with geriatric population and/or end-of-life care is preferred
Knowledge, Skills & Abilities
- Commitment to provide compassionate, patient-centered care
- Ability to communicate clearly and efficiently with patients, families, and PCP staff
- Ability to communicate clearly, serve as a resource to, and partner seamlessly with, all teammates involved in delivering patient care plans
- Ability to monitor a patient’s health, identify key clinical information, and offer timely updates that inform each patient’s care plan
- Language skills consistent with the predominant needs of the population
- Current and unrestricted Pennsylvania Social Worker license in good standing
- Basic Life Support for Healthcare providers (AHA) or CPR/AED for the Professional Rescuer (American Red Cross)
- Driver’s License in good standing
- Ability and means to travel on a flexible schedule as needed; proof of liability and property damage insurance on vehicle used is required