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Social Worker, Care Management - Salinas
COPE Health Solutions
Salinas, USA
Full-time
Mid Level
Onsite
USD 79200-110000 yearly
Discovered 1 weeks ago
Free
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- Assess identified members to determine appropriate members for management early in their disease process and at any time during the continuum of care.
- Complete a comprehensive assessment to identify patient risk and develop a care plan utilizing expertise and judgement to evaluate needs for alternative services as needed.
- Assess members’ Social Determinants of Health, such as housing, food, transportation, and safety in the home.
- Work collaboratively with physicians and community resources including pharmacists, nurses, registered dieticians, and other disciplines to address patient needs as identified in assessments.
- Assess and screen members for behavioral health concerns (depression / substance abuse) utilizing screening tools, including the PHQ2 and 9 Depression screenings, and ensure they are receiving appropriate behavioral health interventions.
- Facilitate any necessary follow-up or referrals for behavioral health needs with local behavioral health providers.
- Develop, facilitate, and communicate a plan of care in partnership with the member, family (or designated representatives), providers, and multidisciplinary care team to assess the options of care including use of benefits and community resources.
- Update care plan to include progress towards achieving established goals and self-management activities.
- Coordinate necessary referrals and authorizations pertinent to patient care and well-being.
- Utilize developed systems, processes, and initiatives to engage patients in relevant social activities necessary to promote wellness and care at the right place and time.
- Facilitate member adoption of strategies to promote physician recommended behavior changes.
- Identify and utilize cultural and community resources and align with the patient’s cultural preferences as much as possible.
- Facilitate the information flow between health representatives and the care team.
- Coordinate care and communicate with multiple providers, internal and external to the practice.
- Act as a resource for both clinical and non-clinical staff [i.e., care coordinators, dieticians, RN Case Managers].
- Attend required training and collaboration sessions [i.e., learning sessions/ practice team meetings] as scheduled.
- Provide and facilitate open communication regarding patient status, with physicians and patient care team.
- Dev elop constructive relationships with internal GLIN population health team members, participating providers, and community resources.
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