Bilingual Medical Social Worker MSW

What You’ll Do

Position Summary The

Senior Guia

systematically intervenes to provide clinical social work and complex case management to patients and their families who have complex psychosocial needs, require assistance with eligibility determination for social programs and funding sources, and qualify for community assistance from a variety of special funds and agencies. This position assesses the patient’s plan of care and develops, implements, monitors, and documents the utilization of resources internally and externally and progress of the patient through the continuum of care. The intensity of care coordination provided is situational and appropriate based on patient need and payer requirements. This role participates in an interdisciplinary team (including Physicians, Case Managers, Staff Nurses and other members of the care team) to provide services for high risk patients and ensure that psychosocial needs are attended to and treated as required across the continuum of care.

Responsibilities Provides

comprehensive

care coordination to an assigned patient caseload

Works collaboratively with patients, family, caregivers, healthcare providers, and external partners to meet complex medical patient needs

As part of a multidisciplinary team, develops and carries out a treatment plan

by the use of

a clinical social work diagnosis,

assessment

and treatment interventions

Intervenes with patients and families

regarding

emotional, social, and financial consequences of illness and/or disability

Assesses,

mobilizes

and provides follow up on family/community resources to meet social care needs

Provides intervention in cases involving elder abuse/neglect, domestic violence, guardianship (temporary/permanent), mental health placement, and sexual assault

Initiates and

• assists
• patients with advance directives
• Collaborates with patients/caregivers to include supportive care, end-of-life decisions, community resources/programs, goal setting, and long-term planning needs
• Formulates care plan of intervention acceptable to the patient, family, and health care team
• Receives referrals for complex patient problem resolution from case managers or clinical care team members
• Works in collaboration with the clinical and case management team on transitions of care planning and referrals to
• post acute
• providers
• Promotes a collaborative process and communication between all health care team members, internal multidisciplinary teams, inclusive patients/clients, families, and significant others to ensure the process of integrated care services are targeted,
• appropriate, and beneficial

Advocates

• utilizing
• knowledge of applicable laws, regulations, government, and insurance benefits as well as practice guidelines and standards of practice
• Advocates for patient and family empowerment and independence to make autonomous health care decisions and access needed services within the health care system

Provides

• follow up
• and
• assistance
• to patients in a variety of settings: in-home, in-clinic, and in the ancillary setting- hospitals, group homes, skilled nursing facilities, etc.
• Documents all interventions in the patient medical record both
• timely
• and accurately including all elements of clinic visits, in home, telephonic engagement, or texting
• Maintains knowledge of Medicare, Medicaid, and other program benefits to
• assist
• patients with resource allocation and choices

Has freedom to

• determine
• how to best
• accomplish
• functions within established procedures

Provides consultation to

• low risk
• guias
• on patients with significant or intensive community resources needs
• Participates in the development and maintenance of case management metrics
• Provides professional education to staff and community

Facilitates

Suvida

sponsored support groups

Other duties as assigned by Guia Manager

What You’ll Bring

Knowledge, Skills, and Abilities

• Acute inpatient hospital social work experience preferred
• Experience managing the needs of Senior/Geriatric populations
• Experience assessing and addressing the social determinant of health
• Working knowledge of ICD-10 and Z codes

Proficiency

• with EMRs, computers, mobile devices, medical devices, and Microsoft Office Suite
• Excellent therapeutic communication and negotiation skills in interactions with patients, families, physicians, and health care team colleagues
• Exposure and/or experience in pre-acute and post-acute care

Expertise

connecting patients and ensuring closed loop referral with community resources and governmental agencies that address complex social needs

Ability to work independently, as well as, to develop collaborative relations with physicians, families, patients, interdisciplinary team members, and community agencies

Education, Experience, Licensure, or Certification Requirements

• Graduate of an accredited Master of Social Work program (MSW)
• preferred

Requires a Licensed Master Social Worker (LMSW)

or equivalent

3-5 years of experience

AND

• CHW certification plus 6- 8
• years
• social work
• experience.
• Must have knowledge of government/community resources as well as Medicare, Medicaid, long-term care, or any other applicable resources/services
• Must have knowledge for transacting LIS, PAP, and SNAP applications and other foundation applications

Must

demonstrate

critical thinking skills, problem-solving abilities, effective communication skills, relationship building skills, and time management skill

Suvida Healthcare provides equal employment opportunities to all Team Members and applicants for employment and prohibits discrimination and harassment of any type with regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

Who We Are

At Suvida Healthcare, we are not just caregivers; we're compassionate advocates dedicated to enriching the lives of our cherished seniors. As a Team Member with us, you will embark on a fulfilling journey where your skills and empathy converge to make a meaningful impact on the well-being of an underserved community and their families. Our multi-disciplinary primary care program is built to address the physical, behavioral, social, and cultural needs of Medicare-eligible Hispanic seniors.

Celebrate diversity and inclusivity in a workplace that attracts, engages, values, rewards, and recognizes the unique needs and backgrounds of both, our patients and our team. We believe that a rich tapestry of experiences,  shared interests, and perspectives enhances the care we provide, making us a stronger, service-centered,  and more compassionate healthcare family and Employer of Choice!  Will you join us
Suvidanos
, to help achieve our Higher Purpose?

What Makes Us Unique

We are an empowered primary care team, clinical operations, and support team creating health equity through an exceptional clinical and consumer experience that improves the quality of life for the people, families, and neighborhoods we serve. We tailor our primary care program to the culture, language, social, and overall well-being of the seniors we serve.

How We Work Our Culture & Core Beliefs Earn Trust Building Relationships Creating Joy Doing Right Improving Every Day Moving Forward Our Promise Purpose Driven Career Competitive Pay Best-In-Class Medical/Dental Coverage Free Mental Health & Life Coaching for Team Members and their Dependents Holiday Time Off with Pay Paid Community Service Day Paid Parental/Family Leave Paid Bereavement Leave Generous Paid Time Off (PTO) 401k Retirement Plan with Company Match And much more....