ACO Medical Social Worker

The ACO Medical Social Worker serves in a collaborative role on the Care Management team, working with the attributed patient population identified as high and/or rising risk via stratification and referral. The MSW role encompasses assessment of the social determinates of health, and planning, facilitation, coordination, evaluation and advocacy for options and services to meet the comprehensive health needs of an individual or family through communication and available resources to promote quality, cost effective outcomes.

Responsibilities include:

• Serves as patient advocate.
• Conducts comprehensive social work assessment, including social determinates to identify barriers to care.
• Provides patient self-management education/counseling with telephonic, verbal, written, virtual and/or electronic monitoring of patient's self-management outcome.
• Implements, coordinates, and updates social work care plan to reduce/remove barriers and closes gaps in care.
• Coordinates care to include referral management between patient, provider, specialists, facilities and community resources.
• Collaborates and communicates with patient, family, providers, care management team members, and other stakeholders.
• Performs age specific assessments and utilizes age appropriate interventions.
• Screens for signs of depression and anxiety using approved evidence-based tools.
• Participates in quality improvement, measurement and data collection to include populations with clinical and financial risk.
• Performs home visits when determined necessary/appropriate.
• Documents in electronic platform, multiple practice EMRs, and paper-based records.
• Provides assistance to patients and families to complete Medicaid and other applications for assistance programs or services.
• Provides education and assistance with advance care planning/advance directives and long-term care planning.
• Develops and maintains relationships with stakeholders at skilled nursing facilities, assisted living facilities, home care agencies, and other healthcare organizations.
• Continually researches available resources for patients to meet their health care goals.
• Actively participates in planning, development and implementation of new initiatives to meet the triple aim – improve quality/patient experience, improve health outcomes, and reduce costs.
• Consults, assesses, refers, and coordinates interventions in cases of suspected or actual situations of child or elder abuse and neglect or other forms of domestic violence and/or sexual abuse.
• Prepares and maintains individual patient and departmental records according to organizational, federal and state regulations; completes statistical information and prepares correspondence as needed.
• Adheres to social work and organizational policies and standards as well as standards from external regulatory agencies and accrediting bodies (e.g. CMS, Department of Public Health).
• Performs other duties as assigned within scope of role
• Keeps current on literature and best practices in field of social work and regulations.
• Maintains a minimum of 30 CEUs every 2 years.

Minimum Qualifications:

• Master’s Degree in Social Work (MSW) required, LCSW preferred
• One year of medical social work experience with Medicare population required
• Community-based or home care social work experience preferred
• Knowledge of discharge and transition of care planning preferred
• Working knowledge of state, county and community resources required
• Must have basic computer literacy, working knowledge of Microsoft Office and clinical database software
• Strong leadership ability and excellent interpersonal, oral and written communication skills
• Ability to work independently and remotely and as part of inter-professional team
• Valid driver's license and ability to travel to patient homes and/or provider sites in New Castle, Kent and/or Sussex counties as needed

Trinity Health's Commitment to Diversity and Inclusion

Trinity Health employs about 133,000 colleagues at dozens of hospitals and hundreds of health centers in 22 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Trinity Health's dedication to diversity includes a unified workforce (through training and education, recruitment, retention and development), commitment and accountability, communication, community partnerships, and supplier diversity.