Social Worker

This position requires meeting with clients in person at their home.

Education: Bachelor’s degree required in social work, psychology, counseling, rehabilitation, gerontology sociology or related field.

Experience: Minimum of one year required in healthcare and/or community-based services. Adult/people with disabilities focused social work preferred.

Special Knowledge, Skills, and Abilities: Knowledge of community-based programs. Ability to work with multidisciplinary team, clients, and their families in home settings.

Responsibilities:

1. Management of clients transitioning from the acute/sub-acute hospital or Skilled Nursing Facility setting back to their home, or clients identified by health care payor in needed care coordination, short-term care management, or assessments.

2. Management of clients referred by payor.

3. Understand and complete all requirements to be credentialed in hospital or health care payor system.

4. Using motivational interviewing, as well as educational and transition coaching tools, to conduct hospital visits and prepare client for a home visit (as applicable).

5. Prepare for and conduct post-discharge visit in the home within 48 hours of discharge (as applicable).

6. Perform in-home or telephonic assessment, HomeMeds (as applicable), and create care plan (as applicable) based on health care contract and scope of work.

7. Perform timely care coordination follow up calls based on intervention being provided.

8. Identify support systems for the client including timeliness of primary care physician visit, especially after hospitalization.

9. Assist in development of a community-based referral network. Organize, coordinate, and conduct reviews of community resources and social service agencies and other psychosocial referral sources for clients.

10. Develop and maintain automated or manual systems and procedures to facilitate on-going program operations.

11. Participates as an active team member in care transitions with internal and external team members.

12. Identify, assess, and respond to crisis situations in a timely fashion, with appropriate interventions.

13. Observe all legal, departmental, health plan and/or hospital regulations.

14. Develop and maintain positive community interactions; build referral relationships in the community and seek new resources

Physical Demands:

This position requires extensive travel locally for hospital and home-based transition coaching or other home-based programs. Work is also conducted remotely in coach’s home. This position requires reliable means of transportation and insurance, and may require certain vaccinations or screenings.

Partners in Care Foundation is an equal opportunity employer. We are committed to complying with all federal, state, and local laws providing equal employment opportunities, and all other employment laws and regulations. It is our intent to maintain a work environment which is free of harassment, discrimination, or retaliation because of age, race (including hair texture and protective hairstyles, such as braids, locks, and twists), color, national origin, ancestry, religion, sex, sexual orientation, pregnancy (including childbirth, lactation/breastfeeding, and related medical conditions), physical or mental disability, genetic information (including testing and characteristics, as well as those of family members), veteran status, uniformed service member status, gender, gender identity, gender expression, transgender status, arrest or conviction record, domestic violence victim status, credit history, unemployment status, caregiver status, sexual and reproductive health decisions, salary history or any other status protected by federal, state, or local laws. All qualified applicants will receive consideration for employment and reasonable accommodations may be made to enable qualified individuals to perform the essential functions of the position.