Company :Allegheny Health NetworkJob Description :GENERAL OVERVIEW This job utilizes principles of care coordination to support patients and their families/caregivers.
The incumbent collaborates with an interdisciplinary team of providers, clinicians, health plans, and external partners while advocating for patients and families/caregivers to coordinate care across the continuum.
The incumbent is an integral member of the Care Management team that aims to improve the quality of care, patient experience, and the health of populations and individuals by addressing social determinants of health impacting wellness.
ESSENTIAL RESPONSIBILITIES: Contributes to and/or completes initial and ongoing comprehensive assessments.
Provides interventions and implements recommendations after engaging patients and their caregivers/families.
Focuses on the individual's risk related to social determinants of health to ensure successful coordination of care across the continuum.
(30%)
Collaborates to provide the safest transition plan for assigned patients (Inpatient/Observation/ED) to ensure a timely discharge and appropriate connection with post-discharge care providers and community-based resources.
(25%)
Educates patients, families/caregivers, and physicians regarding the most appropriate level of care post-discharge and how to access community support.
Advocates for the patient, family/caregiver by effectively communicating with interdisciplinary team members, payers, and post-acute partners to ensure the safest transition.
(20%)
Serves as a resource to provide counseling and intervention related to treatment decisions and end-of-life issues.
Drives collaborative conversations to establish goals of care.
Provides crisis interventions in cases involving Child Abuse and Neglect, Domestic Violence, Adult and Older Adult Abuse, Institutional Abuse, Sexual Assault, Mental Health Disorders, Substance Use Disorders, and Identification of a Surrogate Decision Maker/Guardianship.
(15%)
Promotes individual professional growth and development through certification, mentoring/precepting, and participation on department/hospital/system committees.
(5%)
Supports Department-based goals that contribute to the success of the organization.
(5%)
Other duties as assigned.
QUALIFICATIONS: Minimum Master's degree in Social Work (Incumbents in the role on or before 4/21/2025 have 6 months from hire date to obtain)
Experience in a hospital or healthcare setting
LSW and/or LCSW required (Incumbents in the role on or before 4/21/2025 have 12 months from hire date to obtain)
Act 34 Criminal Background Clearance Certificate
Act 33 Child Abuse Clearance Certificate
Act 73 FBI Fingerprinting Criminal Background Clearance Certificate
Preferred None
Disclaimer: The job description indicates the general nature and essential duties of the role.
It may not include all duties, responsibilities, and qualifications required.
Compliance Requirement: This job adheres to ethical and legal standards, including the company's code of conduct and policies.
Employees may have access to confidential information and must comply with HIPAA, privacy policies, and data security guidelines.
All employees must adhere to applicable laws, regulations, and company policies.
Highmark Health and its affiliates prohibit discrimination based on protected categories and aim for accessibility.
For accommodations, contact HR Services Online at ******.
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