Social Complex Care Manager, Social Worker

We're unique.  You should be, too.

We're changing lives every day.  For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts?  Do you inspire others with your kindness and joy?

We're different than most primary care providers. We're rapidly expanding and we need great people to join our team.

The Community Social Worker (CSW) is a member of the care treatment team including the PCP, other Medical Specialists and Care Nurses. The incumbent in this role is responsible for providing psychosocial assessment, social case work and linkage to community resources for patients who have chronic, life threatening or altering diseases and disorders. The incumbent in this profile advocates for services and resources for the underprivileged and victims of abuse, neglect, or other difficult personal situations to help them maintain an optimum level of health. Community Social Workers will adhere to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance, and policies and procedures as defined by industry standards and the enterprise

​ESSENTIAL JOB DUTIES/RESPONSIBILITIES:

Needs Identification and assessment:

• Conducts timely and appropriate assessment and needs identification, prioritizing patients on the PCP's High Priority Patients (HPP) and Top 40 patient lists. Assesses the patients for psychosocial, financial, family issues, palliative care/end of life issues, home safety, etc. that negatively impact their health outcomes.

• Communicates with PCPs and interdisciplinary Care Team in order to support and advise concerning social needs and resources available in community resource database.

Medicaid and other benefit eligibility assessments:

• Conducts appropriate assessment of needs and financial benefit eligibility.

• Assesses patients for Medicaid criteria and assists with application process as needed.

• Assists patients to obtain community resources/services as appropriate, e.g. meals, medications, housing, daycare, HHA and other SDoH needs as identified.

Resource coordination and prevention: 

• Serves as care coordinator linking patients with internal and external resources, prioritizing high risk patients with the greatest needs.

• Facilitates connections to community resources as identified by the patients SDoH Wellness Screening.

• Works with patient, family, and interdisciplinary care team to facilitate applications for higher level of care.

• Maintains an accurate repository of social wellness tools and resources for the care team's awareness and utilization with patients in need.

Communication:

• Maintains communication with interdisciplinary team members by attending appropriate meetings (i.e. weekly Super Huddles and Hospital and Community Care Team (HCT) meeting.)

  • Provides consultation in an integrated health care environment regarding social determinants of health and community resources.

Timely and accurate documentation:

• Maintains timely, accurate, thorough and appropriate documentation/reports per company policies and procedures. Initial psychosocial assessments will be completed within 48 hours. All follow- up visits, phone calls and collaborative contacts will be documented within 24 hours. Assures documentation meets billing guidelines.

Additional duties may include:

• Works closely with the Hospital and Community Care Team (HCT) to secure the appropriate level of care post hospital/SNF discharge. Further interventions may be conducted in the center, by phone call or patient's home.

• Performs other duties as assigned and modified at manager's discretion.

We're ChenMed and we're transforming healthcare for seniors and changing America's healthcare for the better.  Family-owned and physician-led, our unique approach allows us to improve the health and well-being of the populations we serve. We're growing rapidly as we seek to rescue more and more seniors from inadequate health care. 

ChenMed is changing lives for the people we serve and the people we hire.  With great compensation, comprehensive benefits, career development and advancement opportunities and so much more, our employees enjoy great work-life balance and opportunities to grow.  Join our team who make a difference in people's lives every single day.

Current Employee apply HERE

Current Contingent Worker please see job aid HERE to apply

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