Provide a range of social work services in collaboration with PHC staff to meet the psycho-social and care coordination needs of members. Responsible for the assessment and care coordination of the psycho-social needs of members, families and/or caregivers to help promote positive coping skills, reduce the risk of premature institutionalization, assist individuals in maintaining independence in the community and increase stabilization of social determinants.

• Travels to meet members, families and/or caregivers in the community to address case
  management and care coordination needs.
• Develops an individualized care plan addressing the psycho-social elements and non-medical barriers to health in an effort to promote and ensure optimal care coordination of
  the member’s needs.
• Conducts interview assessments with individuals, families and/or caregivers to identify a
  member’s needs, goals and/or barriers.
• Sets priorities according to treatment goals and member’s preferences in a timely manner.
• Supports successful transitions and coordination of services across the care continuum
  (ex: pediatric to adult settings, acute/post-acute to community, adaptation to disability or
  trauma, etc.) via effective and frequent communication and collaboration with providers,
  the member, family and/or caregiver.
• Arranges, coordinates and monitors the use of community services/resources available to
  members, family and/or caregivers. (ex: housing options, financial assistance, special
  education options, vocational training/employment, legal aid services, etc.)
• Assists members in selecting appropriate resources and/or contacting resources on behalf
  of the member. Provides support in obtaining necessary forms, filling out
  documents/applications when appropriate.
• Provides education and support to members, families, caregivers and/or PHC staff
  regarding conservatorship, Public Guardianship, Power of Attorney and/or Authorized
  Representative options for members with identified needs.
• Uses Motivational Interviewing strategies and clear communication/limit setting to
  promote member’s self-management, reduce risk of system(s) dependency, and improve
  health and well-being.
• Documents interventions and activities according to departmental policies and
  procedures.
• Collaborates with colleagues to provide education and support to members with
  identified psycho-social and/or resource needs.
• Participates as part of a multidisciplinary team in PHC’s integrated rounds; presenting
  complex member cases when needed and offering suggestions or support to others.
• Maintains working knowledge of public/private community resources and fosters
  collaborative working relationships on behalf of PHC.
• Actively participates in outreach meetings or case conferences in the community,
  including hospitals, skilled nursing facilities, community-based organizations, etc.
• Engages in essential skills training as directed or assigned.
• Other duties as assigned.

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

HIRING MANAGER:

 $45.04 - $56.30

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.