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Posted: 08-Sep-23
Location: Denver, Colorado
Salary: Open
Internal Number: R3159
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Department
ACS-CHS Grants FundedJob SummaryUnder general supervision, the Health PlanDenver Health Pediatrics at Denver Public Schools School-Based Health Center (SBHC) Social Work Care Coordinator (SWCC) is responsible for facilitating and coordinating the care delivered to an assigned group ofpatients members using multidisciplinary and member/family collaboration to ensure quality and cost effectivecost-effective outcomes are delivered within appropriate care coordination parameters. Coordination involves assessment of care needs, planning, support, and evaluation of member care and related outcomes. Activities to be performed are screening and assessment of medical, behavioral health and social determinants needs and gaps in care, collaboration with the Member to develop a care plan with SMART goals, scheduled outreach to support member in achieving their goals and supporting the Members patientspatients' self-efficacy to navigate systems. SWCC communicates closely with the Member's care team inclusive of: the Member, designated health representatives, primary care provider, behavioral health providers and other care coordinators involved with the Member's Patient's care. Encounters occur face to face, telephonically, and electronically with members patients in clinic and in other community-based settings. SBHCs.Position is an active contributor in the development of systems (e.g.e.g., work flowsworkflows, clinical pathways, assessments) to improve the care of assigned member patient populations. Helps ensure compliance with state, federal and third party payor requirements.
Essential Functions:
- Utilizes Care Coordination Processes:
- Systematically collects focused data relating health needs and concerns of memberpatient, group, or population.
- Establishes and maintains memberpatient-centered relationships.
- Analyzes assessment data to determine opportunities for health promotion, health maintenance or health related problem needs and statements.
- Identifies and executes evidence-based interventions to support the Memberpatient in achieving their health goals.
- Identifies and works towards expected outcomes in a plan of care individualized for a specific memberpatient, group or population.
- In collaboration with the patientMember, develops a care plan that identifies strategies and alternatives to attain expected outcomes. Utilizes competent, evidence based, telephone encounters and electronic communications according to regulatory requirements and standards, as well organizational policies and procedures.
- Conducts systematic evaluation of outcomes of care coordination in relation to structures and processes prescribed by plandetermined by grant.
- Documents in readable, understandable language according to professional, regulatory, and agency standards.
- Documents and disseminates results of care to memberpatient, caregivers, and others involved in the care or situation, as appropriate, in accordance with contractual requirements, state and federal laws, regulatory requirements, and Denver Health policy. (35%)
- Provide Care Coordination Services:
- Coordinates the delivery of care within the clinic setting, throughout the organization, and across health care settings.
- Provides relevant information across the care system, within Denver Health and with other healthcare systems and payers when member care is transferred between and among different specialties and/or within one or more organizations.
- Provides information to the health care team including the memberpatient, family, and caregiver regarding available resources and benefits for health care services that ensures member choice and safe, timely transition.
- Serves as point of contact within and among healthcare services and organizations.
- Coordinates community resources.
- Assures designation of primary responsibility among team members for each aspect of care plan, avoiding duplication and fragmentation.
- Facilitates continuity of care using the multidisciplinary collaboration, and coordination of all appropriate healthcare services and community resources across the care continuum.
- Orients member/caregiverpatient to health care delivery system, services, access, and resources. (30%)
- Health Teaching and Promotion:
- Identifies barriers to goals and strategies to address.
- Provides personalized education for optimal wellness.
- Encourages preventative care such as immunizations and cancer screening.Well Child Checks.
- Promotes appropriate utilization of resources.
- Assists and educates caregiver when member is unable to participate.
- Incorporates therapeutic communication, health literacy, cultural, and linguistic needs and preference into education and goals.
- Supports members patients and caregivers in developing skills for self-efficacy to promote, maintain, or restore health such as healthy lifestyle tips, risk-reducing behaviors, age and developmental needs, daily living activities, and preventative care. (20%)
- Care Coordination
- Responsible for a defined caseload of Members enrolled in the DHMP Medicare Choice Dually-eligible Special Needs Program (DSNP) patients who are identified as having a medium or low risk acuity level using data from a variety of sources, including the Memberpatient, their caregivers, providers, administrative claims data, pharmacy data and other inputs.
- The DSNP Model of Care is a well-defined model requiring a comprehensive health risk assessment (HRA), individualized care plan (ICP) and integrated care team (ICT) review of the ICP. This routine is completed at least annually and more frequently when the Member experiences a change in condition, as evidenced by hospitalization, movement to a residential place of care or other event.
- Obtains Member patient consent to participate in the program as well as to share clinical information with the Member's Patient's care team.
- Works collaboratively with the patientMember to set SMART (specific, measurable, attainable, realistic and time-limited) goals. and to graduate the Member to lower-intensity care programs and self-care within reasonable timeframes.
- Works under the supervision and advice of the Supervisor who can provide insight into medical conditions, treatments, medications and answer medically-related questions as needed. (15%)
Education:
- High School Diploma or GED Required
Work Experience:
- 1-3 years One year of direct member care experience in acute, ambulatory care or community based care Required
Licenses:
Knowledge, Skills and Abilities:
- Bilingual in English/Spanish, preferred.
- Knowledge of emotional and social factors that impact patient’s health.
- Excellent interpersonal skills.
- Skilled in identifying problems/opportunities to improve care.
- Ability to help the patient and family to understand, accept, and follow medical recommendations.
- Ability to utilize resources, such as family or community agencies, to assist the patient to resume life in the community.
- Ability to collect key information from the patient, family, and the community, as part of the social work assessment.
- Ability to communicate to the appropriate staff, information about the patient.’s discharge plan.
- Experience with windows-based computer programs and ability to use computer for data analysis and data display, required.
- Experience with Medical Management platforms used to document care coordination services, preferred.
Shift
Days (United States of America)Work Type
Partial Year (Ten Month)Salary
$24.33 - $35.24 / hrBenefits
Competitive pay
Outstanding benefits
Education opportunities
Shared leadership and advancement opportunity
State-of-the-art facilities
Immediate retirement plan matching
Professional clinical advancement program
Participation in evidence-based projects
Public Service Loan Forgiveness (PSLF) eligible employer
National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer
Our Values
Respect
Belonging
Accountability
Transparency
All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.
Denver Health is an integrated, high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver's 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, a Public Health Institute, an HMO and The Denver Health Foundation.
As Colorado's primary, and essential, safety-net institution, Denver Health is a mission-driven organization that has provided billions in uncompensated care for the uninsured. Denver Health is viewed as an Anchor Institution for the community, focusing on hiring and purchasing locally as applicable, serving as a pillar for community needs, and caring for more than 185,000 individuals and 67,000 children a year.
Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.
We strongly support diversity in the workforce and Denver Health is an equal opportunity employer (EOE).
Denver Health values the unique ideas, talents and contributions reflective of the needs of our community. For read more about our commitment to diversity visit: https://www.denverhealth.org/for-professionals/careers/diversity-and-inclusion
