Social Worker MSW Senior - Community Outreach in Santa Fe, NM

Summary:

The Senior Care Social Worker is an integral member of an interdisciplinary team (IDT) and provides comprehensive psychosocial needs assessments for patients and families dealing with aging and serious and/or life threatening illnesses. They help alleviate the burden on family members by assessing the patient’s and family’s economic, psychosocial, and spiritual needs, and then helping to obtain resources to meet those needs. This position also works closely with the care coordination team to ensure timely and thoughtful transitions of care. The senior care social worker will take a leadership role in the development of quality improvement initiatives that support the goals of age friendly and senior care across the care continuum. This position will work closely with our clinician group, and may be required to provide coverage in all clinic settings.

Responsibilities:

• Provide assertive patient support in navigation of health care and community based system of service
  • Complete Patient Assessments
  • Identify Patient and Family Goals
  • Address patient needs including medical, emotional, mental, spiritual, physical and social using the lens of critical intersectional theory
• Assist with identification and registration of benefits needed by patient.
• Community Collaboration
  • Demonstrate working knowledge of internal and community resources
  • Identify appropriate service agencies, and provide strong lineage to resources, and referrals for services
  • Ensure continuity of care during patient navigation
  • Facilitate and attend care planning meetings with agencies, service providers, medical providers, or patient supports
  • Engage all patients in community settings identified by the patient and navigator as safe for all parties involved
• Complete and maintain accurate timely documentation in EMR.
• Provide supportive and practical supports to patients with an emphasis on the needs of aging population.
• Complete accurate reporting of data required for program improvement and performance outcomes related to population health and the senior care program.

Requirements:

Education: 

• Master’s in Social Work

Certification/Licenses: 

• Current social work licensure in the state of NM

Skills:

• Must be comfortable and effective working in teams. Provide holistic, person-centered care by partnering with patients to address individual physical, emotional, social, and spiritual needs
• Provide services in accordance with Age Friendly guidelines.
• Excellent compassionate communication skills with hospital coworkers, providers, community partners, any family or natural supports a patient has, and the patients themselves
• Establish and maintain rapport with patients, families, and other members of the health care team, identified community partners, or resources, and complete all required documentation of contact within 72 hours
• Work effectively within interdisciplinary and transdisciplinary care teams to promote a team approach to patient care
• Computer skills including Epic, Microsoft Office Suite, Outlook, and the ability to enter data and complete forms completely with minimal errors
• Work independently, and be self-motivated to meet with and assist patients in resolving complex care issues
• Complete medical record documentation to ensure quality and accuracy
• Work independently to advocate for patient care with medical providers and community resources
• Act as a resource to other staff regarding high quality community resources that support the identified population.

Experience: 

• Two years clinical experience in hospital, long-term care or hospice settings or working with marginalized groups. Experience in program development and leadership preferred.

Work Schedule:

8AM - 5PM Monday-Friday

Work Type:

Full Time