Complex Care Coordinator (Lsw)

Mission Statement:

Our Mission is to be the premier regional provider of integrated, community-based healthcare by combining evidence-based clinical practices, outstanding patient service, innovative care partnerships, and team-driven excellence, within a healthy fiscal environment.

Licensed Social Worker (LSW) sought to work as a part of an interdisciplinary complex care management team. The LSW will report to the RN Complex Care Manager and will be an integral part of the Specialized Health Services interdisciplinary team across the PHMC nurse-managed Health Network sites. The LSW will work at these health centers and in the community with diverse and underserved patient populations The LSW will provide community-based clinical social work, case management and outreach services to help coordinate care and improve patient health outcomes. This position provides clinical hours towards the LCSW. The LSW will receive clinical supervision from an LCSW from within the Health Network as well as training and support the Health Network social services team.

Responsibilities:

• Provide multidisciplinary assessments by evaluating all relevant information to determine needs and barriers in health care, social supports, and access to behavioral health services

• Actively participate as a member of the interdisciplinary health care team (IDT) by providing input and developing creative strategies to address health, behavioral health, and psychosocial issues

• Collaborate with medical and auxiliary providers in developing health care plans and goal based on identified needs

• Provide outreach and engage with clients by eliminating social, cultural, linguistic, and educational barriers to promote and encourage self-care

• Facilitate communication and positive relationship building between clients and medical providers

• Ensure that clients obtain timely and coordinated access to appropriate health and social services by promoting and modeling advocacy skills

• Individual counseling including:

• Functional and strength-based assessment and diagnosis

• Psychoeducation for patients and their support systems

• Medication adherence counseling and disease self management counseling

• Motivational Interviewing to develop behavioral strategies aimed at symptom reduction

• Brief problem solving cognitive intervention aimed at modifying negative thinking and promoting self efficacy

• Substance use/abuse evaluation, identification of maladaptive coping strategies, and development of harm reduction strategies

• Document all services in a timely manner in the electronic health record system

Skills:

• Thorough knowledge of community resources
• Knowledge of DSM 5 behavioral health conditions and working knowledge of chronic diseases
• Ability to exercise strong clinical judgment, independent analysis, and critical thinking skills
• Excellent time management skills and attention to details in order to help develop sustainable programming, attend to caseload expectations and ensure timely documentation
• Strong interpersonal, organizational, and oral/written communication skills

Experience:

• Medical literacy
• Experience working in behavioral medicine and health psychology
• Experience working as a member of an interdisciplinary team
• Comfort with evidenced-based interventions, including cognitive behavioral therapy, motivational interviewing , SBIRT
• Experience with crisis intervention and substance abuse highly desired
• Comfort working with diverse populations ( i.e. race, ethnicity, diagnoses, age ranges)

Education Requirement:

• Masters Degree in Social Work from an accredited school required
• Licensed Social Worker (in Pennsylvania) required

Physical Demands:

• Position requires standing/walking 2/3 of the time and sitting approximately 1/3 of the time, use of hands 2/3 of the time, reach with hands and arms under 1/3 of the time, stoop, kneel, crouch or crawl under 1/3 of the time, talk or hear over 2/3 of the time. Position requires lifting up to 10 lbs. up to 1/3 of the time

Work Environment:

• Moderate noise (examples: business office with computers and printers, light traffic). Exposure to blood borne pathogens that requires use of personal protective equipment

Salary:

Commensurate with education and experience

PHMC is an Equal Opportunity and E-Verify Employer.