Care coordination is the deliberate organization of patient care activities to facilitate the appropriate delivery of health care services. This position provides comprehensive outpatient support for patients as assigned and uses biopsychosocial assessments to develop patients plan of care. Develops, implements, monitors and documents the utilization of resources and progress of the patients care through advocating and facilitating options and services to meet the patients behavioral and health care needs. This position builds relationships with community partners and catalogs available resources to meet the needs of our patients and their families. The Lead Social Worker (SW) assists the Manager in providing ongoing support to the Care Management Team and support the ongoing development of the Social Workers within the PCCN Care Management Team. The Lead Social Worker assists with staff audits, developing and maintaining desktop procedures, training new staff and participating in Continuous Quality Improvement projects. This position works independently, receiving supervision of work activities from the Manager of Care Coordination.
- Family-Centered care that focuses on the need of the child first and values the family as an important member of the care team
- Excellence in clinical care, service and communication
- Collaborative within our institution and with others who share our mission and goals
- Leadership that set the standard for pediatric health care today and innovations of the future
- Accountability to our patients, community and each other for providing the best in the most cost-effective way.
- a) Provides guidance, mentoring, and direction as appropriate for ongoing staff development.
- b) In collaboration with the Care Management leadership team plans, recommends and implements approved protocols, policies, and guidelines to support overall organizational values and mission.
- c) Participates in departmental operational initiatives to evaluate and improve patient health, quality measure performance, and patient experience.
- d) Provides supervision and consultation to Care Coordination Team Members.
- e) Collaborates with other PCCN Care Team leads, Manager of Care Coordination, Director of Clinical Integration and PCCNs Medical Director.
- f) Coordinates work activities of assigned staff to ensure achievement of established goals, objectives, and outcomes.
- g) Leads employees through ongoing goal setting, training and performance feedback.
- h) Participates in performance appraisals for assigned staff.
- i) Provides team leadership, demonstrates strong, consistent clear communication and serves as central point of information for team members.
- j) Conducts case audits for Social Worker care management staff and Social Work Tech to ensure documentation meets departmental and URAC compliance standards.
- a) Assesses primarily telephonically the childs biopsychosocial status, which may include, but is not limited to, available financial and community resources, parents / patients comprehension of medical conditions, mental health status, available support systems, safety issues, risk for abuse/neglect, suicide risk assessment, coping skills, cognitive abilities, etc. as requested by the assigned RN Care Manager, Care Navigator or as determined by the Social Worker`s professional judgment.
- b) Identifies any barriers that impede treatment and/or recovery, provide information to the Interdisciplinary Care Team and participate in proactive care planning.
- c) Identifies resources to address family needs or care barriers to promote safety and wellbeing, as well as optimize parent involvement in the childs care plan.
Documentation and Communication
- a) Completes clinical record documentation as required by departmental procedures in a timely manner.
- b) Cultivates and maintains effective interaction/communication with members of the interdisciplinary clinical care team and proactively engages children and families in care coordination across the continuum of care.
- c) Participates in organizational and departmental operational initiatives to improve care management support.
Coordination of Care
- a) Assists in development, implementation and revision of individual care plans in a manner that promotes sound financial stewardship and patient-family advocacy.
- b) Provides education regarding medical compliance, crisis intervention, support
- groups, etc.
- c) Identifies potential risk factors and barriers to care. Proactively collaborates with members of the interdisciplinary clinical care team to identify needs and documents a clear and comprehensive care plan to address risk factors and barriers to care.
- d) Assures proper care transitions by collaborating with hospital staff, PCCN physicians/providers, payers, referral coordinators, and various community services.
- e) Facilitates referrals and education to assist with timely access to providers and monitors for appropriate follow-up.
- f) Advises families on available resources and programs through the educational system, such as 504s and IEPs and advocates on behalf of children and families when necessary.
- a) Maintains professional competency by regularly participating in a variety of educational programs and in-services, reviewing relevant professional publications, participating in community based committees related to service line responsibilities, and/or participating in professional societies to ensure ongoing awareness of current methodologies, practices and philosophies as applied to the patient care population.
- b) Maintains current knowledge of community and other resource networks to meet child and family needs, to provide relevant resources, and to assist as necessary, with connecting the child/family to the relevant resources.
- a) Provides excellent customer service routinely in interactions with all customers, i.e. coworkers, patients, families, health plans, physicians, etc.
- b) Responds to email within 24 hours or one business day.
- Performs miscellaneous job related duties as requested.