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Job Objective: A brief overview of the position.
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The Social Worker is responsible for the delivery of behavioral and healthcare management services in the Ambulatory Care setting to a variety of patient populations across the lifespan; coordinates the complex needs of patients and their families as well as psychosocial assessment for patients with complex psychiatric, social, medical and financial needs.
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Reports to
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Director Ambulatory Care Coordination
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Supervises
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N/A
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Ages of Patients
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Pediatric
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Adolescent
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Adult
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Geriatric
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Blood Borne Pathogens
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- Minimal / No Potential
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Qualifications
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Education
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Required: Master’s degree in Social Work
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Licensure/Certification
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Preferred: California Licensed Clinical Social Work (LCSW)
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Experience
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Required: Two (2) years clinical social work experience
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Preferred: Managed care experience, recent medical or mental health experience
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Essential Responsibilities
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Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations.
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Completes psychosocial assessment of patients according to professional standards. Documents using facts only without attitude, judgment or opinions. Includes all telephone calls made with person’s name and phone number.
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Coordinates utilization of patient and community resources to facilitate achievement of safe and effective care management plans and accomplishment of goals.
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Ensures that any information that would be helpful, as appropriate, to facilitate continuity of care are communicated to all members of the patients interdisciplinary team using organizations electronic health record (EHR).
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Develops strong relationships with community health resources to ensure appropriate patient access.
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Navigates/connects patients with health and community services
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Screens patients, upon referral or according to high risk criteria for psychosocial needs. Conducts psychosocial assessment when indicated to identify emotional, social and environmental issues impacting quality outcomes.
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Provides crises intervention, supportive counseling and advocacy to assist patients and/or family with adjustment associated with illness, hospitalization and/or alternative care placement.
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Helps patients understand their rights in regards to patient choice, medical treatment, advanced directives and other related issues.
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Helps patient/family understand, accept and follow medical recommendations within the context of self-determination.
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Initiates appropriate referrals to the Ethics Committee, Physician Advisor, Risk Management or Legal Services, as appropriate.
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Facilitates resolution of issues surrounding patient care in a compassionate manner, functioning as a patient advocate.
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Serves as a resource to hospital staff and physicians concerning social issues (i.e., APS, CPS, Domestic Violence, the 5150 process, DPOA, mental health).
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Facilitates resource acquisition for the unfunded patient, as available.
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Provides education to patient and families around issues related to adaptation to the patient’s diagnosis, illness, treatment, and/or life situation.
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Collaborates with physicians, nursing and other healthcare disciplines to promote continuous process improvement, which results in efficiency, cost effectiveness and the highest level of clinical excellence.
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Works with Ambulatory Care Coordination team, and practice leadership to continuously evaluate processes, identify problems, and propose process improvement strategies to enhance patient care and ensure key performance indicators are met.
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Provides culturally competent clinical services which are relevant to patient and family.
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Conducts regular follow ups with patients to evaluate progress and response to plan of care.
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Provides education to patients of all ages based on needs assessment.
- Performs other duties as assigned.
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Located in the heart of the Coachella Valley, you have access to resort-style living and world-class amenities throughout Southern California.
