Job Description

Job - Ambulatory Social Work Case Manager

Department: Care Coordination

Location – Cambridge, MA

Duration – 3+ Months

Pay Rate- $40-45/hr.

Job Summary

• Assists HUHS patients and their families in coordinating medical, social, emotional, insurance, and vocational issues related to injury or illness.
• Conducts psychosocial assessments, either in-person or telephonically, in order to develop a comprehensive out-patient care plan that guides work with patient.
• Collaborate with physicians, nurses, support staff, community agencies, and other health care professionals to implement safe, effective, and timely patient care.
• Communicates with treating clinicians on areas of concern and provides clinical updates to clinicians on a regular basis.
• Provides timely and appropriate documentation in patient's electronic medical record.
• Participates in assuring that HUHS is in the forefront of applying Case Management principles.
• Participates in achieving the goal of cost effective, high quality, continuous care to patients; communicates effectively with clinicians, patients, and team leader to achieve this goal.
• Utilizes team leaders as appropriate for clinical consultation and to apprise of legal, ethical, risk issues that may affect the patient, family, or health services.
• Maintains quality assurance and improvement activities in compliance with HUHS standards.
• Assists in the development of reports and resources required by other departments.

Qualifications/Requirements

Required

• Master’s in social work.
• Current license to practice social work in Massachusetts, either LCSW or LICSW.
• Minimum of 2 years of social work experience in medical setting.
• Familiar with managed care and case management principles.

Preferred

• Ability to work independently and as part of a team.
• Familiar with care needs of medically complex young adult, adult, and geriatric populations.
• Ability to provide a high level of customer service to patients, staff, and external customers in a professional, service-oriented, respectful manner in using
• skills in active listening and problem solving. Excellent organizational, analytical, problem solving and interpersonal skills.

DUTIES AND RESPONSIBILITIES

• Assumes responsibilities of an active caseload, including following patients throughout the continuum of care.
• Provides Ambulatory Case Management services to identified HUHS patients through a process of research, patient interview, development of care plans and monitoring of care.
• Researches clinical history of identified patients using all necessary and appropriate resources.
• Provides a clinical assessment either telephonically or as appropriate in person to
• assess patient’s needs and perception of their health status.
• Provides pre-operative outreach and assessment to identified student athletes.
• Assists HUHS patients and their families coordinate medical, social, emotional, insurance, and vocational issues related to injury or illness.
• Educates patients and families regarding Advance Directives and assists patients and families in completing Advance Directives.
• Promotes effective communication with hospitals and their departments.
• Educates them to resources available at Harvard University Health Services.
• Participates in/attends IM Team Meetings and daily huddles.
• Participates in/attends HUHS committees/work groups when appropriate.
• Communicates with primary care clinician, patient, and home care provider to
• ensure medically necessary services.
• Regularly communicates with patients requiring post- discharge service to assess patient satisfaction and that appropriate services are in place.
• Evaluates utilization and effectiveness of Home Care provider network.
• Assess quality of care of Home Care providers as well as responsiveness.
• Addresses areas of concerns with manager to ensure optimal quality of care for patients.
• Educates patients/families about non-skilled services for patients when necessary.
• Assists in arranging for these services when patients/families allow.

• Acts as a liaison between patients and HUHS to assist in coordinating follow up
• services.
• Ensures the department maintains effective communication with other HUHS Departments.
• Educates HUHS staff about Care Coordination’s scope of service and how to utilize HUHS case managers as resources. ·
• Identifies areas of improvement; recommends and implements solutions.
• Actively participates in project development.
• Collaborates with manager to implement, evaluate, and support programs to maximize utilization of available resources.
• Assists in maintaining a Quick Reference Resource Guide.
• Educates patients/families/caregivers as to trajectory of certain disease processes and level of support/care needed throughout disease process.
• Educates patients/families about health insurance processes and when appropriate benefits.
• Directs patients/families where to learn more about health insurance benefits. · Provides supportive counseling to patients and families to enhance coping skills and resolve concerns. ·
• Provides supportive counseling to patients and families considering changes in living situations or managing changes related to a medical condition.
• Collaborates when appropriate with BCBS MA Nurse Case Manager in case management of HUSHP/HUGHP patients with complex medical and psychosocial needs.
• Develops a comprehensive treatment plan. Monitors and assesses appropriateness of treatment plan and makes appropriate modifications as necessary. · Communicates with PCP or treating clinician on areas of concern in addition to ongoing updates on clinical progress. · Reports incidences of suspected abuse and neglect of children, elders, and individuals with disabilities to appropriate designated state agency. · Organizes and participates in patient case conferences as needed Provides timely, appropriate, comprehensive clinical documentation in patient's electronic medical record. · Provides cross coverage for co-workers as needed. · Attends department staff meetings. · Is punctual and prepared for duties at start of shift. · Is reliable and dependable in coming to work. · Gives appropriate notice to manager when unexpected circumstances call for staff member to be away from work. · Utilizes time productively. · Participates in the orientation of new staff members. · Identifies own learning needs and requests assistance from others when needed. · Works independently, as well as collaboratively, with all members of the health care team. · Treats patients with dignity, respect, and compassion. · Provides prompt care/service and behaves sensitively in all interactions. · Deals with others in a sensitive, tactful, positive, and courteous manner. · Accepts and acts upon feedback. · Utilizes team leader as appropriate for clinical consultation and to apprise of legal, ethical, risk issues that may affect the patient, family, or health services.

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