Job Description
THIS POSITION WILL REQUIRE TRAVEL TO OUR CENTRAL REGION CLINICS
The Ambulatory Social Worker reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.
The Ambulatory Social Worker II collaborates and participates in the coordination of screening, assessment, and careplanning activities with patients and their families with complex psychosocial needs, while supporting continuity of care as needed. Utilizes expertise and problem solving skills to achieve optimal clinical outcomes within effective resources and timeframes. Provides psychosocial assessment, intervention services and ongoing support to patients who meet program criteria.
_ Responsibilities:_
As a key member of an ambulatory care coordination team:
- Partners with ambulatory nursing and pharmacy team members to achieve system goals and objectives around care coordination for NM populations identified with complex clinical and psychosocial needs.
- Develops and implements appropriate assessment based treatment plan.
- Leads the process on Advance Directive Completion.
- Informs and coordinates with interdisciplinary clinical team in order to ensure high quality of care and make joint decisions that are in the patients best interest.
- Applies specialized clinical knowledge and advanced clinical skills in the areas of assessment, diagnosis, and treatment of mental, behavioral, addictions disorders or conditions and makes appropriate referrals or transfers to the correct level of care.
- Communicates in a calm approach, utilizing active listening skills.
- Utilizes translators appropriately in order to understand and be understood.
- Identifies solutions/changes in patient plan of care or community resources.
- Utilizes critical thinking to identify and screen high risk social cases.
- Provides treatment planning, psychosocial interventions, health education, financial counseling, referrals, and discharge/transition planning.
- Provides resources, including education materials, to patients and families in the areas of financial assistance, transportation, scheduling, and community resources to support the care plan.
- Analyzes patient situation for the provision of care.
- Emphasis on addressing the social and emotional needs of the patient and family that may impact on the patient's response to medical treatment. These needs may include, but are not limited to, adjustment to illness, poor or limited coping abilities, functional impairment, mental illness, guardianship issues, compliance, need for additional resources due to limited funds available, substance abuse, cultural differences, death, dying, bereavement, and family welfare, including abuse, neglect, and domestic violence.
- Provides timely and effective interventions for patients and families in emergency and crisis, including referrals to appropriate support resources.
- Serves as a lead resource and assists with referrals in coordinating charity and financial resources, guardianship issues, family problems or conflicts, and competency issues.
- Assists with the maintenance of information and referral lists relative to post-acute care resources.
- Uses effective service recovery skills to solve problems or service breakdowns when they occur.
- Educates team members regarding the socio-economic, emotional and cultural issues that impact care delivery, coping skills, and response to treatment.
- Serves as an advocate for the patient and family.
- Telephonically and personally meets with patients, family and care team members to coordinate psychosocial, financial, housing and transportation needs.
- Collaborates with the care team and community linkage for patients and families with complex social, economic, and emotional needs.
- Participates in care conferences and rounds.
- Keeps all members of the care team apprised of the current state and plan of care.
- Collaborates with care team members to identify at risk populations and opportunities to improve care delivery and on-going support, thus increasing efficiencies and effectiveness.
- Partners with the post-acute care providers and shares appropriate and pertinent information in order to create a seamless and safe discharge plan.
- Knowledgeable of insurance and reimbursement processes.
- Demonstrates teamwork by helping co-workers within and across departments.
- Communicates effectively with others, respects diverse opinions and styles, and acknowledges the assistance and contributions of others.