Social Worker

 

The Social Worker provides support to patients with complex health needs and are an integral part of our coordinated care team which includes physicians, nurse practitioners, nurses, care coordinators, social workers, dietitians, educators and pharmacists. The Strive Social Worker must be able to work successfully both in person and remotely via telephone or videoconferencing technologies. They will be assigned a patient census and will round on patients in a variety of clinical settings such as hospitals, SNFs, dialysis centers, and the patient’s home. The Strive Social Worker is responsible for addressing non-clinical barriers to care and screening for social determinants of health.  

 

Essential Functions

 

Arrange, coordinate, monitor, evaluate, and advocate for support services to meet patient clinical, behavioral and social health needs

Provide counseling, education, and crisis intervention

Build a strong relationship with the patient and their family and then investigate the social factors that are influencing their health with empathy, trust, and compassion

Educate the patient and patient’s family on condition, treatment, and benefits of selected interventions

Collaborate with multidisciplinary treatment team including patients’ primary care providers, case managers, care coordinators, and others

Understand what the patient wants for his or her life and work to remove the barriers

Collaborate with the Nurse Practitioner to ensure clinical instructions are followed by the patient and the patient needs are communicated to the NP

Support and coach care team on effective identification of emotional and psychosocial health needs and promote sensitivity to mental health in their daily practice

Help patients locate and access community resources. Assist patients above and beyond making a referral. Social workers will help drive engagement with resources.

Educate the entire care team on community resources and pull together resource information so they can make simple referrals

Assess home environments to understand deeper issues impacting patient health

Get involved with patient’s adherence challenges and high risk situations (like high ER utilization) to solve for them

Develop collaborative relationships with dialysis unit social workers

 

Minimum Qualifications

 

Master’s degree in social work required

Licensed Clinical Social Worker Certificate

Minimum 5 years experience working in chronic disease management (e.g. internal medicine, renal, cardiac, pulmonary, or oncology care) or critical care setting

State specific licensure required

 Visit patients in home environment

 

Preferred Qualification

 

Ability to develop and maintain patient relationships

Knowledge of surrounding community resources

Strong communication skills

 

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