Geriatric social worker job description

OUR WHY: 5-STAR SERVICE CULTURE

At Physician Partners LLC, it’s our commitment, our passion, and our culture that sets us apart. We don’t just talk the talk - we believe in it and live by it. We are revolutionizing the healthcare industry by focusing on quality, not quantity. Our core value is always to deliver 5-Star Service. And by doing so, we are successfully able to achieve our mission of Better Health.

Physician Partners IPA/MSO aligns payors and providers across all populations with the people, processes, technologies, and information to transition to value-based care and achieve high-quality, cost-effective care with patients and physicians.

We are a preferred partner for driving value-based care adoption and delivering personalized, secure, and seamless healthcare experiences. We take great care of our team, patients, providers, and affiliates. To us, it’s about providing quality care for better outcomes! When our patients win with Better Health, Physician Partners wins.

Summary/ Objective:

The Top 5% of the Medicare Advantage population is the highest risk and highest cost segment that consumes upwards of 50% of all utilization. This population presents a challenge in the coordination of medical, behavioral, substance abuse, and social determinants in improving their health outcomes. We are embarking on a new care program that aims to treat this population to optimize patient health. The program will provide a holistic approach to caring for these patients in both a virtual and home setting. The Licensed Clinical Social Worker (LCSW) will work with a multi-disciplinary team to create an environment for regular monitoring and interventions for the various conditions a patient may have. The LCSW will identify and address behavioral, substance abuse, and social determinants to improve health outcomes.

Essential Functions:

• Engage patients mostly virtually but occasionally in person and assist with their behavior, substance abuse, and social determinants challenges
• LCSW partners with multi-disciplinary teams and refer to appropriate no- or low-cost community services.
• Involves the patients’ families and primary caregiver(s) as needed
• Effectively collaborates with all those involved in the patient’s care, including health services contractors Consult with and advise the clinical l Team regarding patient needs or concerns.
• Maintains current progress notes and other documentation in the patient's Electronic Medical Record (EMR)
• Coordinates referrals to health plan behavioral and substance abuse Specialists when appropriate

Supervisory Responsibility:

• No direct reports
• LCSW to report to the Practice Administrator (Operational/Administrative) and the Extensivist Physician (Clinical)

Work Environment:

• The LCSW would operate remotely with assigned visits to patient homes as needed

Physical Demands:

• Manage and coordinate inbound and outbound telephonic outreach
• Ability to document in Electronic Database systems.

Position Type/ Expected Hours of Work:

• This is a full-time position and core hours of work and days are Monday to Friday 8:00 a.m. -
  5:00 p.m.
• Extended hours to accommodate patient urgent and emergent care needs will be expected

Travel:

• Approximately 10% of travel is required to the patient home, as needed
• Travel to Corporate or Regional Offices may be required for training or meetings.

Required Education/ Experience:

• Bachelor’s Degree in Licensed Clinical Social Work
• Must have a valid Florida LCSW license
• Two years of social work experience in health care and a minimum of one-year experience working with a geriatric population

Additional Eligibility and Qualifications:

• Age-specific competency in working with the elderly and knowledge of community services for the elderly and their families
• Requires limited travel to patient homes and residences
• Knowledge of social work principles and practices, including case management and counseling techniques
• Ability to use Electronic Medical Record (EMR) system to document patient encounters
• Effective communication and interpersonal skills
• Valid Florida Drivers License
• For PhyPartners business units, the satisfactory completion of a pre-placement Tuberculosis the test is a requirement for this position

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