SKILLS & COMPETENCIES

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  Practices the WellBe mission: To help our patients lead healthier, meaningful lives by delivering the most Complete Care.
• Performs psychosocial assessments and provides therapeutic services to patients and their families.
• Work closely with Behavioral Health Medical Director to manage complex patient cases and transitions of care
• A resource for the WellBe communities in managing complex Behavioral Health cases.
• Manages complex behavioral and psychosocial needs that result in improved clinical and financial outcomes
• Maintains constant communication with patients when addressing their concerns and goals and helping them keep positive attitudes
• Builds rapport with patients and their families and relay all concerns to WellBe provider/IDT
• Assists members to effectively utilize available resources to meet their personal health goals and help them develop their own capabilities.
• Monitors patient progress and adjusts patient treatment plan as needed
• Coordinates with other healthcare providers, agencies and community resources in order to create a thorough treatment plan addressing social, cultural, and financial needs
• Collaborates with the interdisciplinary team and participate in regularly scheduled team meetings
• Ensures compliance with regulatory agencies and WellBe clinical guidelines
• Following a thorough assessment completed by an Advanced Practice Clinician (APC), the WellBe social worker partners
• Partner with community team to refer patients to appropriate no or low-cost community services that support health and independence such as Meals On Wheels (MOW), local Area Agencies on Aging (AAA), Senior & Assistance Programs, and transportation resources.
• Involves the patients’ families and primary caregiver(s) as needed to achieve the best care decisions and outcomes.
• Effectively collaborates with all those involved in the members’ care, including health services contractors (i.e., Home Health, Hospice, Community Agencies), to meet the patients’ care goals.
• Consults with and advises the Clinical Team regarding the relationship of social, emotional, and cultural factors to health and medical care, and to the availability of social services in the community.
• Complies with safety policies and procedures, identifying and immediately reporting any potential or actual unsafe acts or conditions to their supervisor/team. Takes necessary measures to ensure a safe environment for oneself, co-workers, contractors, participants, visitors and others.
• Consistently meets or exceeds WellBe targets for productivity, customer service, quality assessment, and performance targets.
• Understands the importance of community involvement and participates as appropriate in activities that link WellBe to its communities.
• Maintains current written progress notes and other documentation on the member Medical Record including signed and dated documentation for all service performed the day the service is provided.
• Participates in program and policy development of the WellBe Social Work program.
• Other tasks needed to accomplish team’s objectives/goals

Educational/ Experience Requirements:

• Master’s Degree in Social Work
• 5+ years clinical social work experience with the geriatric population
• Two years social work experience, preferably in health care, and minimum one-year experience working with a frail/elderly population.

License, Certification, Registration

• LISW Licensure required

Required Skills and Abilities:

• Current unrestricted LISW license in applicable state(s) required.
• Age specific competency in working with the elderly and knowledge of community services for the elderly and their families.
• Ability to make psychosocial assessments and develop and implement viable care plans
• Must be familiar with EHR medical documentation
• Strong computer skills, including Word, Excel, and Powerpoint
• Strong verbal, written, presentation, and interpersonal communication skills
• Bilingual in English/Spanish preferred.
• Ability to work effectively in a team environment.
• Knowledge of social work principles and practices, including case management and counseling techniques.
• Ability to empathize with clients
• Ability to provide after-hours services as needed
• Ability to leverage internal and external resources as part of a patient’s treatment plan
• Experience writing assessments and reports to monitor client progress
• Valid driver’s license, have access to a car and willingness to drive to patient homes/patient location as well as an active auto insurance policy

Travel requirements: Travel may be required up to 80% locally.

The preceding functions may not be comprehensive in scope regarding work performed by an employee assigned to this position classification. Management reserves the right to add, modify, change or rescind the work assignments of this position. Management also reserves the right to make reasonable accommodations so that a qualified employee(s) can perform the essential functions of this role