Job Description

Job Description

Responsibilities

Job Summary: The Transitional Care (TOC) Social Worker is responsible for collaborating with member of the interdisciplinary care team to facilitate member's successful transition from acute or post-acute care setting to home and is accountable for utilizing the social work general practice model to affect transition to home outcomes for Prominence Health Plan members. He/she is responsible for engaging with members in need of resourcing to avoid poor health outcomes, frequent emergency room visits, and hospital readmissions.

The TOC Social Worker receives referrals or identifies hospitalized high-risk, complex members in need of social services and communicates with all entities involved in the care of the member to promote and maximize care coordination. Key aspects of the TOC Program protocols are based upon inpatient and post-discharge workflows. Inpatient workflow includes conducting assessments, member and family education regarding available resources, identification of member-level concerns regarding discharge, and anticipation of potential gaps in care. The inpatient encounters are designed to educate members/caregivers surrounding their post discharge needs and to empower them to play an active and informed role in managing their care post-discharge.

Additionally, the TOC Social Worker may organize support groups or counsel family members to assist them in understanding, dealing with, and supporting the member either during the inpatient stay or post discharge. To support continued development the Social Worker may plan and conduct programs well as develop or advise on social policy to combat social problems, and impact community health issues.

Qualifications

Education:

* Minimum: Master's Degree in Social Work

Experience:

* Experience in the Social Work field, preferably transitional or case management social work. Candidate must have knowledge of social and physical factors that affect functional status at discharge, and knowledge of community resources to meet post discharge clinical and social needs.

License & Certifications:

* Minimum active, Licensed Clinical Social Worker in the state of Nevada

* Ability to obtain licensure in various states

* Preferred: CCM, C-SWCM, or CMCP

Language Skills:

Ability to effectively communicate in English, both verbally and in writing.
Knowledge, Skills and Abilities:

Proficiency in gathering and interpreting empirical evidence, formulating recommendations, action plans and interventions to improve the overall organization strategy.
Simultaneous action at varying stages--initiation, follow through, and completion--on a number of different projects.
Demonstrated ability to research, analyze and interpret state/federal regulations related to health insurance and healthcare.

Demonstrated ability to communicate verbally and with technical writing in a way that effectively conveys project background, objectives, activities, evaluations, conclusions, and recommendations.
Demonstrated skills in critical thinking, problem solving, and the analysis, interpretation and evaluation of complex information.
Demonstrated ability to work independently with minimal supervision.
Demonstrated ability to maintain effective collaborative working relationships with staff.
Resourceful, detail-oriented, and able to assimilate and analyze a wide variety of information, often working under deadline pressure with a variety of levels of staff.

Strong project management skills.
Computer Skills: Smartsheet, SharePoint, Microsoft Office (Word, Excel, PowerPoint), and database software.