Inspire health. Serve with compassion. Be the difference.

Job Summary

Accountable for managing targeted patient populations in order to achieve efficient and effective care delivery. Includes coordinating, facilitating, monitoring and evaluating interventions to achieve desired outcomes. Functions as part of an interdisciplinary team to guide and track individuals across time and delivery sites. Provide social work services for targeted populations and serve as social work resource for department.

Essential Functions

• All team members are expected to be knowledgeable and compliant with Prisma Health's purpose: Inspire health. Serve with compassion. Be the difference

• Assists in development of an initial Plan of Care that highlights actual and potential self-management improvement opportunities.

• Facilitates and monitors implementation of Plan of Care.

• Coordinates patient/family participation in Plan of Care and self-management.

• Coordinates patient education to achieve Plan of Care.

• Performs home visits as necessary to evaluate possible barriers to attainment of self-management goals and develops strategies to overcome barriers.

• Participates in the development and execution of the Plan of Care.

• Demonstrates expertise in care management and serves as resource to the interdisciplinary health care team.

• Integrates knowledge of external and internal regulatory requirements into the review and management of cases.

• Works to provide continuity of care.

• Serves as bridge across the clinical setting.

• Utilizes and incorporates knowledge of efficiency and effectiveness indicators (example-PQRI) when coordinating and facilitating Plan of Care.

• Increases knowledge of best practices and clinical standards of care and incorporates knowledge into practice.

• Documents in the medical record and on team tools, accurately reflecting collaborative care planning, interventions and evaluation against defined targets and goals.

• Adheres to nationally accepted standards of Case Management.

• Demonstrates adaptability to new standards and to the evolution of workforce development activities.

• Performs other duties as assigned.

Supervisory/Management Responsibilities

• This is a non-management job that will report to a supervisor, director or executive.

Minimum Requirements

• Education - Master's degree in Social Work

• Experience - One (1) year experience in healthcare experience preferred

In Lieu Of

• Team members employed in this job prior to July 1, 2020 are grandfathered under prior educational and experience requirements. In addition, team members must be certification eligible and will have one year to obtain required certification(s).

Required Certifications, Registrations, Licenses

• LMSW (Licensed Masters Social Worker) or LISW (Licensed Independent Social Worker)

• Driving, if an essential function of position, is determined by leadership and designated Facility assignment. Driving or home visits may/may not be required based on Facility and role assignment. Incumbents in positions with driving designated as an essential function, are subject to an MVR review and Prisma’s eligibility requirements for driving.

Knowledge, Skills and Abilities

• Knowledge of office equipment

• Computer skills (word processing, spreadsheets)

Work Shift

Day (United States of America)

Location

Corporate

Facility

7002 Value-Based Care and Network Services

Department

70028455 Ambulatory Care Management

Share your talent with us! Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.

Accountable for managing targeted patient populations in order to achieve efficient and effective care delivery. Includes coordinating, facilitating, monitoring and evaluating interventions to achieve desired outcomes. Functions as part of an interdisciplinary team to guide and track individuals across time and delivery sites. Provide social work services for targeted populations and serve as social work resource for department. Essential Functions. All team members are expected to be knowledgeable and compliant with Prisma Health's purpose: Inspire health. Serve with compassion. Be the difference. Assists in development of an initial Plan of Care that highlights actual and potential self-management improvement opportunities. Facilitates and monitors implementation of Plan of Care. Coordinates patient/family participation in Plan of Care and self-management. Coordinates patient education to achieve Plan of Care. Performs home visits as necessary to evaluate possible barriers to attainment of self-management goals and develops strategies to overcome barriers. Participates in the development and execution of the Plan of Care. Demonstrates expertise in care management and serves as resource to the interdisciplinary health care team. Integrates knowledge of external and internal regulatory requirements into the review and management of cases. Works to provide continuity of care. Serves as bridge across the clinical setting. Utilizes and incorporates knowledge of efficiency and effectiveness indicators (example-PQRI) when coordinating and facilitating Plan of Care. Increases knowledge of best practices and clinical standards of care and incorporates knowledge into practice. Documents in the medical record and on team tools, accurately reflecting collaborative care planning, interventions and evaluation against defined targets and goals. Adheres to nationally accepted standards of Case Management. Demonstrates adaptability to new standards and to the evolution of workforce development activities. Performs other duties as assigned. Supervisory/ Management Responsibilities. This is a non-management job that will report to a supervisor, director or executive. Minimum Requirements. Education - Master's degree in Social Work. Experience - One (1) year experience in healthcare experience preferred. In Lieu Of. Team members employed in this job prior to July 1, 2020 are grandfathered under prior educational and experience requirements. In addition, team members must be certification eligible and will have one year to obtain required certification(s). Required Certifications, Registrations, Licenses. LMSW (Licensed Masters Social Worker) or LISW (Licensed Independent Social Worker)Driving, if an essential function of position, is determined by leadership and designated Facility assignment. Driving or home visits may/may not be required based on Facility and role assignment. Incumbents in positions with driving designated as an essential function, are subject to an MVR review and Prisma’s eligibility requirements for driving. Knowledge, Skills and Abilities. Knowledge of office equipment. Computer skills (word processing, spreadsheets)Work Shift. Day (United States of America)Location. Corporate. Facility 7002 Value-Based Care and Network Services. Department 70028455 Ambulatory Care Management.

search terms: Ambulatory Care+Social Worker