Social Worker, House Calls

The House Calls Social Worker is responsible for clinical evaluation and management of patients in a home setting, as assigned by the Primary Care Physician, Medical Director, Hospitalist or Care Manager. Use your natural gift of education and persuasion to help patients and their families in an outpatient setting deal with a variety of complex conditions.  You will assist our team of providers by acting as a consultant for patients with complex psychosocial needs in the patient’s home.   In this vital role, you will help patients understand their rights and responsibilities, provide counseling and crisis intervention, and assist patients in finding information and referrals to community resources.

Essential Functions

  • Consistently exhibits behavior and communication skills that demonstrate Tandigm Health’s commitment to superior customer service, including quality, care, and concern for each and every internal and external customer.
  • Performs in-home psychosocial evaluations of patient’s physical, social and emotional functioning. This may include financial and family support as needed.
  • Consistently exhibits behavior and communication skills that demonstrate Tandigm’s commitment to our mission and values.
  • Develops a treatment plan or plan of care in collaboration with the care management team.
  • Provides community resource information and performs referral and liaison activities as necessary for the patient’s ambulatory care.
  • Acts as a consultant to patients requiring information on Advanced Directives.
  • Participates as appropriate in weekly patient care rounds for patients.
  • Assists patients and their families with transitions of care out of post-acute care settings for patients with complex discharge needs.
  • Participates on an assigned basis in educational training for employees and providers related to the psychosocial aspects of physical and emotional illness/disability.
  • Acts as a resource to other Social Workers within the organization on difficult to manage cases.
  • Perform patient evaluation and documentation within 48-hours.
  • 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

  • Master’s degree in Social Work (MSW required) from an accredited school of social work education with a specialization in clinical practice
  • Licensed or registered in the state of practice as required by state regulations.

Experience

At least one-year experience in a hospital or other healthcare setting, 3 or more years preferred

Knowledge, Skills & Abilities

  • Demonstrate commitment to social work values and code of ethics
  • Experience with geriatric or end of life care preferred
  • Proficiency in Microsoft office and ability to type 25wpm
  • Deep knowledge of community resources and commitment to innovation
  • Ability to interface effectively with culturally diverse patients and communities, providers, management, and employees of the organizations.
  • Ability to exercise objectivity and good judgment relating to difficult and emotionally-charged situations.
  • Strong time management and organizational skills in order to meet documentation guidelines
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