Social Work Coordinator

Benefits

Additional Information

We are recruiting for a mission-driven Social Work Coordinator to join our team! We're with you for life's journey. At Denver Health, purpose isn't just something we believe in-it's something we live every day, for life's journey. Our Values Respect | Belonging | Accountability | Transparency Department ACS-CHS Grants Funded Job Summary Under general supervision, the Health PlanDenver Health Pediatrics at Denver Public Schools School-Based Health Center (SBHC) Social Work Care Coordinator (SWCC) is responsible for facilitating and coordinating the care delivered to an assigned group ofpatients members using multidisciplinary and member/family collaboration to ensure quality and cost effectivecost-effective outcomes are delivered within appropriate care coordination parameters. Coordination involves assessment of care needs, planning, support, and evaluation of member care and related outcomes. Activities to be performed are screening and assessment of medical, behavioral health and social determinants needs and gaps in care, collaboration with the Member to develop a care plan with SMART goals, scheduled outreach to support member in achieving their goals and supporting the Members patientspatients' self-efficacy to navigate systems. SWCC communicates closely with the Member's care team inclusive of: the Member, designated health representatives, primary care provider, behavioral health providers and other care coordinators involved with the Member's Patient's care. Encounters occur face to face, telephonically, and electronically with members patients in clinic and in other community-based settings. SBHCs. Position is an active contributor in the development of systems (e.g.e.g., work flowsworkflows, clinical pathways, assessments) to improve the care of assigned member patient populations. Helps ensure compliance with state, federal and third party payor requirements. Essential Functions : Utilizes Care Coordination Processes: - Systematically collects focused data relating health needs and concerns of memberpatient, group, or population. - Establishes and maintains memberpatient-centered relationships. - Analyzes assessment data to determine opportunities for health promotion, health maintenance or health related problem needs and statements. - Identifies and executes evidence-based interventions to support the Memberpatient in achieving their health goals. - Identifies and works towards expected outcomes in a plan of care individualized for a specific memberpatient, group or population. - In collaboration with the patientMember, develops a care plan that identifies strategies and alternatives to attain expected outcomes. Utilizes competent, evidence based, telephone encounters and electronic communications according to regulatory requirements and standards, as well organizational policies and procedures. - Conducts systematic evaluation of outcomes of care coordination in relation to structures and processes prescribed by plandetermined by grant. - Documents in readable, understandable language according to professional, regulatory, and agency standards. - Documents and disseminates results of care to memberpatient, caregivers, and others involved in the care or situation, as appropriate, in accordance with contractual requirements, state and federal laws, regulatory requirements, and Denver Health policy. (35%) Provide Care Coordination Services: - Coordinates the delivery of care within the clinic setting, throughout the organization, and across health care settings. - Provides relevant information across the care system, within Denver Health and with other healthcare systems and payers when member care is transferred between and among different specialties and/or within one or more organizations. - Provides information to the health care team including the memberpatient, family, and caregiver regarding available resources and benefits for health care services that ensures member choice and safe, timely transition. - Serves as point of contact within and among healthcare services and organizations. - Coordinates community resources. - Assures designation of primary responsibility among team members for each aspect of care plan, avoiding duplication and fragmentation. - Facilitates continuity of care using the multidisciplinary collaboration, and coordination of all appropriate healthcare services and community resources across the care continuum. - Orients member/caregiverpatient to health care delivery system, services, access, and resources. (30%) Health Teaching and Promotion: - Identifies barriers to goals and strategies to address. - Provides personalized education for optimal wellness. - Encourages preventative care such as immunizations and cancer screening.Well Child Checks. - Promotes appropriate utilization of resources. - Assists and educates caregiver when member is unable to participate. - Incorporates therapeutic communication, health literacy, cultural, and linguistic needs and