Social Worker - Gulf Coast Market

About the role

POSITION SUMMARY

The Social Worker will utilize interventions to enhance patient and family functioning and emotional well-being and access appropriate, agreed-upon services. They collaboratively develop patient goals, monitor progress, address barriers to goal achievement, and evaluate outcomes of individualized care plans. This role provides training guidance and collaborative feedback to staff and providers in managing complex psychosocial patient issues, aligning with Sage Health’s objectives. Social workers also engage patients, create trusting relationships, and provide care coordination and management to patients with social determinants of health challenges, high emergency department and inpatient utilization rates, and significant financial vulnerability. This position will support the Gulf Coast market, including Mobile, AL, Montgomery, AL, and Gulfport, MS.

What you'll do

PRIMARY RESPONSIBILITIES:

• Ensure patient information remains secure and confidential.

• Develop a database of grant-funded and community resources, i.e., food banks, transportation, churches, etc.

• Participate in center and market interdisciplinary team meetings, i.e., Weekly Utilization Medical Cost Meeting

• Assist patients in applying for government and community assistance or additional support, i.e., Medicaid, energy assistance, etc.

• Provide concise and thorough documentation through progress notes, including progression and attainment of goals, referrals to internal and external agencies, and contact/involvement with the patient’s family.

• Support the members in improving their well-being by staying out of the hospital and attending regular visits to their primary physician via education, clinical resources, and membership follow-up.

• Support the members in ensuring the pick-up of their prescriptions by providing education, quality compliance, and membership follow-up.

• Act as a liaison and advocate between the patient, family, physician, and facilities/agencies

• Proactively engage the members to manage their own health and healthcare decisions.

• Provide members with education on community resources and benefits.

• Listen actively, communicate with empathy, and respectfully gather information.

• Conduct outreach to encourage participation in Sage Health-related programs, services, and providers.

• Use methods that promote learning and positive behavior change.

• Use a variety of interactive teaching and coaching methods for different learning styles

• Evaluate complex patient and family situations with legal, ethical, and psychosocial components.

• Collaboratively develop patient goals, monitor progress, address barriers to goal achievement, and evaluate outcomes of individualized care plans.

• Assessment will reflect interdisciplinary collaboration and be comprehensive about the patient’s age, diagnosis, support systems, and anticipated extent of intervention.

• Network proactively with and demonstrate a working knowledge of community resources

• Demonstrate and apply knowledge of State rules and Federal regulations that ensure safety, quality of life, and protection of patient rights.

• Assist patients with identifying and accessing financial assistance programs and other resources to address financial barriers to care.

• Assist patients with shelter and housing-related needs by connecting them with appropriate community resources and support services.

• Conduct weekly patient “tuck-in” calls to identify and address care needs before the start of the weekend and help coordinate appropriate resources or follow-up.

• Provide support and care coordination for patients with end-of-life (EOL) care needs, including collaboration with patients, families, providers, hospice, and other appropriate resources.

• Participate in discharge planning for patients requiring post-discharge services such as transitions to skilled nursing facilities, assisted living facilities, outpatient dialysis, Acute Rehab, hospice, and transportation needs.

• Recommend consultation requests as appropriate.

• Perform other duties as assigned

Qualifications

REQUIRED QUALIFICATIONS:

• Currently resides in the Sage Health Medical Center City/County

• Valid driver's license, car insurance, and access to an automobile

• Must be able to travel between multiple healthcare facilities, i.e., centers, hospitals, skilled nursing facilities, and patient homes.

• Ability to travel locally up to 90% of the time.

• Must have at least two years of experience within the community/city.

• State-licensed BSW or MSW

• Experience working with the needs of vulnerable populations.

• Excellent interpersonal, written, and verbal communication skills

Reports To: Operations Director

About Sage Health

We believe all seniors regardless of means deserve concierge primary care & wellness, without the concierge fees. They’ve earned it.