Social Work Care Advisor IHCI

Join Community Community Health Network was created by our neighbors, for our neighbors. Over 60 years later, “community” is still the heart of our organization. It means providing our neighbors with the best care possible, backed by state-of-the-art technology. It means getting involved in the communities we serve through volunteer opportunities and benefits initiatives. It means ensuring our dedicated caregivers can learn and grow to stay at the top of their fields and to better serve our patients. And above all, it means exceptional care, simply delivered — and we couldn’t do it without you. Make a Difference The Innovative Healthcare Collaborative of Indiana (IHCI) is a joint venture between Community Health Network and Deaconess Health System. Its goal is to support our sponsors and partners in their strategic evolution to positively impact and improve the healthcare delivery system. This position is primarily REMOTE but there is potential for some physician office-based duties. Patient coordination will be telephonic. This role will provide both direct social work care management to various high-risk patient populations, as well as provide psychosocial, environmental and financial consultation to other members of the care team. You will serve as a critical member of the integrated care team. Exceptional Skills and Qualifications Applicants for this position should be able to collaborate with others in a team setting, have excellent communication skills, and a positive attitude toward problem-solving. - LSW or LCSW in the State of Indiana required. - Bachelor’s degree in social work required. - Master’s degree in social work preferred. - 2 years of experience providing social work services within a variety of population health and/or value-based care program settings preferred. - 2 years of knowledge of care resources for targeted populations. Comfort with technology including Microsoft suite of products. Prior experience using electronic health records including data capture, data mining and reporting required. - 3 years of medical or community Social Work experience providing patient-centered outreach, behavioral health services, needs assessment and support required. - Care Plan: Engages patients and caregivers in developing active care planning to focus on behavioral, clinical, social and environmental concerns and needs for the patient. Develops Plan of Care based on assessment to link patients to proper demographic resources. Connects patients with primary care, behavioral health, respite and other community- based services. Ensure that required data is accurate and consistently captured in the EMR. Acts as liaison and escalates clinical care issues to the IHCI RN Care Advisor when indicated. Communicates with nursing staff or situation that requires nursing judgment. - Resources: Develops and maintains a comprehensive inventory of local community resources, improving accessibility for patients and providers. Solid understanding of Medicare, Medicaid, and third-party payer guidelines for a comprehensive understanding of which community and governmental resources are covered for their patient. Links patients to local resources such as housing support, medication assistance, finance and insurance assistance, as well as other needed resources, as appropriate. - Assessment: Evaluates the needs of the patient through psychosocial, environmental, and financial assessment to determine specific social needs, make referrals and follow-up with patients weekly, and as needed. Assesses the patient’s knowledge of their clinical condition and provides education and self-management support based on the patient’s preferences and financial resources. - Advocate: Utilize a variety of outreach strategies to engage various patient populations. Obtains services and serves as advocate on behalf of patients.