What You’ll Do
Position Summary
The Senior Guia systematically intervenes to provide clinical social work and complex case management to patients and their families who have complex psychosocial needs, require assistance with eligibility determination for social programs and funding sources, and qualify for community assistance from a variety of special funds and agencies. This position assesses the patient’s plan of care and develops, implements, monitors, and documents the utilization of resources internally and externally and progress of the patient through the continuum of care. The intensity of care coordination provided is situational and appropriate based on patient need and payer requirements. This role participates in an interdisciplinary team (including Physicians, Case Managers, Staff Nurses and other members of the care team) to provide services for high risk patients and ensure that psychosocial needs are attended to and treated as required across the continuum of care.
Responsibilities
- Provides comprehensive care coordination to an assigned patient caseload
- Works collaboratively with patients, family, caregivers, healthcare providers, and external partners to meet complex medical patient needs
- As part of a multidisciplinary team, develops and carries out a treatment plan by the use of a clinical social work diagnosis, assessment and treatment interventions
- Intervenes with patients and families regarding emotional, social, and financial consequences of illness and/or disability
- Assesses, mobilizes and provides follow up on family/community resources to meet social care needs
- Provides intervention in cases involving elder abuse/neglect, domestic violence, guardianship (temporary/permanent), mental health placement, and sexual assault
- Initiates and assists patients with advance directives
- Collaborates with patients/caregivers to include supportive care, end-of-life decisions, community resources/programs, goal setting, and long-term planning needs
- Formulates care plan of intervention acceptable to the patient, family, and health care team
- Receives referrals for complex patient problem resolution from case managers or clinical care team members
- Works in collaboration with the clinical and case management team on transitions of care planning and referrals to post acute providers
- Promotes a collaborative process and communication between all health care team members, internal multidisciplinary teams, inclusive patients/clients, families, and significant others to ensure the process of integrated care services are targeted, appropriate, and beneficial
- Advocates utilizing knowledge of applicable laws, regulations, government, and insurance benefits as well as practice guidelines and standards of practice
- Advocates for patient and family empowerment and independence to make autonomous health care decisions and access needed services within the health care system
- Provides follow up and assistance to patients in a variety of settings: in-home, in-clinic, and in the ancillary setting- hospitals, group homes, skilled nursing facilities, etc.
- Documents all interventions in the patient medical record both timely and accurately including all elements of clinic visits, in home, telephonic engagement, or texting
- Maintains knowledge of Medicare, Medicaid, and other program benefits to assist patients with resource allocation and choices
- Has freedom to determine how to best accomplish functions within established procedures
- Provides consultation to low risk guias on patients with significant or intensive community resources needs
- Participates in the development and maintenance of case management metrics
- Provides professional education to staff and community
- Facilitates Suvida sponsored support groups
- Other duties as assigned by Guia Manager
What You’ll Bring
Knowledge, Skills, and Abilities
- Acute inpatient hospital social work experience preferred
- Experience managing the needs of Senior/Geriatric populations
- Experience assessing and addressing the social determinant of health
- Working knowledge of ICD-10 and Z codes
- Proficiency with EMRs, computers, mobile devices, medical devices, and Microsoft Office Suite
- Excellent therapeutic communication and negotiation skills in interactions with patients, families, physicians, and health care team colleagues
- Exposure and/or experience in pre-acute and post-acute care
- Expertise connecting patients and ensuring closed loop referral with community resources and governmental agencies that address complex social needs
- Ability to work independently, as well as, to develop collaborative relations with physicians, families, patients, interdisciplinary team members, and community agencies
Education, Experience, Licensure, or Certification Requirements
- Graduate of an accredited Master of Social Work program (MSW) preferred
- Requires a Licensed Master Social Worker (LMSW) or equivalent 3-5 years of experience AND CHW certification plus 6- 8 years social work experience.
- Must have knowledge of government/community resources as well as Medicare, Medicaid, long-term care, or any other applicable resources/services
- Must have knowledge for transacting LIS, PAP, and SNAP applications and other foundation applications
- Must demonstrate critical thinking skills, problem-solving abilities, effective communication skills, relationship building skills, and time management skill
Suvida Healthcare provides equal employment opportunities to all Team Members and applicants for employment and prohibits discrimination and harassment of any type with regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.