LCSW (Social Worker) Population Health

Employment Type

Full time

Shift

Description:

Position Purpose: Under supervision of clinical leadership from Holy Cross Physician Partners, the Population Health Social Worker provides care management for members attributed to specially defined populations. Additionally, the Population Health Social Worker will act as the primary resource for the Population Health team and Holy Cross Medical Group for patients with complex social needs. The Population Health Social Worked will attend and occasionally lead weekly case review meetings and provide insight for complex cases being comanaged by the Care Management RNs and Community Health Workers.

The goals of the Population Health Social Worker are to coordinate and manage care to meet the multiple social needs of patients being referred by Physicians, Care Managers, and Community Health Workers. They assist the patient with complex social and psychosocial needs and acts as an advocate. Care management may be a continuous or intermittent process; the Population Health Social Worker assesses needs, develops individualized care plans, coordinates services, collaborates with interprofessional members of the care team, facilitates access to resources, monitors and evaluates outcomes, and documents such interventions appropriately within the legal medical record.

What You Will Do

• Completes behavioral health and applicable assessments and makes referrals to outpatient and community resources as appropriate. Displays excellent knowledge and practice of psychosocial assessment skills, including social and emotional factors, counseling for long-range health planning and decision-making, community resource planning, and crisis intervention. Exhibits expertise in behavioral health psychosocial assessment, motivational interviewing, and coping techniques if applicable.
• Uses problem solving approach in providing social services with consideration to the patient and family's culture, past experience, socioeconomic status, and educational background. Collaborates with appropriate providers, facilities, external healthcare organizations throughout the continuum of care and communicates with an interdisciplinary team to develop and maintain positive working relationships while providing for the diverse needs of members and families. \
• Functions as a coordinator and care manager of a defined health population, with modifiable risks, across multiple care settings and for multiple physicians/health care providers or health plan counterparts. Integrates evidence-based clinical guidelines, preventive guidelines, and protocols, in the development of individualized care plans that are member-centric, promoting quality and efficiency in the delivery of health care.
• Continually monitors member/family response to plan of care and revises the care plan as indicated. Provides self-management support with a focus on empowering the member/family to build capacity for self- care. Fosters a team approach and includes member/family as active members of the team.
• Provides education and coaching and engages members using motivational interviewing skills. Collaborates with health plan representatives to further mutual clinical and administrative outcomes, as applicable.
  
  

Education

Minimum Qualifications:

Master’s degree in social work required

Licensure/Certification

Licensed Clinical Social Worker by the State of Florida

• Experience: Minimum experience preferred is 4 years in Social Work; 2 years in a medical setting
• Experience with adult medicine in primary care/ambulatory care, ED, critical care, or hospital medical-surgical setting, including health plans or post-acute care such as home health agency. Care/Case management experience preferred.
• Epic experience preferred.
• Current knowledge of legal, regulatory, and accrediting requirements and standards related to the practice of Social Work.
• Current knowledge of county, state, and federal programs (ex: Medicare, Medicaid, Social Security, SSI, and Veteran benefits).
• Respects diverse opinions, values, and religious and cultural ideals.
• Demonstrates ability to work autonomously and practice effectively in a fluid, dynamic, and rapidly changing environment.
• Displays influential qualities including effective time management, communication skills (verbal, written, listening), problem solving, critical thinking, priority setting, and delegation.
• Exhibits an outcome and continuous quality improvement focus with the ability to interpret and synthesize data.
• Develops positive, longitudinal relationships and sets appropriate boundaries with members/families.
• Demonstrates proficiency in use of computer and other applicable technology.
• Reliable transportation as needed for potential travel to local facilities/meetings.
  
  

Position Highlights And Benefits

• Comprehensive benefit packages available, including medical, dental, vision, paid time off, 403B, and education assistance
• We serve together in the spirit of the Gospel as a compassionate and transforming healing presence within our communities
• We live and breathe our guiding behaviors: we support each other in serving, we communicate openly, honestly, respectfully, and directly, we are fully present, we are all accountable, we trust and assume goodness in intentions, and we are continuous learners communicate openly, honestly, respectfully, and directly, we are fully present, we are all accountable, we trust and assume goodness in intentions, and we are continuous learners
  
  

Ministry/Facility Information

• Holy Cross Hospital in Fort Lauderdale, Florida is a full-service, non-profit Catholic hospital, sponsored by the sisters of Mercy and a member of Trinity Health.
• We are committed to providing compassionate and holistic person-centered care.
• We are the only Catholic hospital in Broward and Palm Beach counties and are not for profit. We are part of Trinity Health, one of the largest multi-institutional Catholic health care delivery systems in the nation. Together, we serve people and communities in 21 states from coast to coast, providing nearly 2.8 million visits annually.
• Comprehensive benefits that start on your first day of work
• Retirement savings program with employer matching
  
  

Legal Info

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.

Our Commitment to Diversity and Inclusion

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.