Social Worker-Care Management - Evernorth Care Group

Summary

The Social Worker is an integral member of the Evernorth Care Group's Care Management (CM) Department.

The CM team, is integrated into the primary care team at Evernorth Care Group (ENCG) Healthcare Centers and support clinicians to improve the health of the patients we serve, with a focus on the management of high- and rising-risk, disease-burdened patients.

This position provides professional, courteous, and friendly assistance to ENCG patients as they engage in the care delivery system.

The Social Worker provides the patient with supports and services to address need, acts as a strong patient advocate, and helps to break down barriers to care.

The Social Worker forms strong relationships with patients by guiding them through challenging situations and addressing social needs.

The Social Worker is an integral part the patient care team which includes the Primary Care Provider, Nurses, Care Managers, Care Navigators, Integrated Behavioral Health Clinicians and Clinical Pharmacy.

They use various tools and guidelines to ensure patients are engaged in self-advocacy, informed decision-making, and have access to community resources.

Duties


* Acts as a community resource expert for all patients, regardless of lines of business.


* Coordinate with patient's medical and behavioral providers to ensure a holistic care plan.


* Assist with coordination of care of the high-risk, most complex cases, providing brief behavioral health interventions using evidenced-based techniques.


* Coordinate care for identified patients with comorbidities in collaboration with the provider.


* Connects patients/family with financial resources such as AHCCCS/ALTCs when long term placement needs are identified.


* Screen and assess patients for common mental health and substance use disorders, leveraging evidence- based tools, as well as consider social determinants of health and comorbid medical conditions.


* Refer patients with mental health issues to appropriate plan resources or state funded mental health services.


* Communicates effectively during complex or emotional patient interactions, utilizing negotiation skills to facilitate patient outcomes.


* Evaluate the effectiveness of alternative care services to ensure that cost effective, quality care is maintained.


* Partner with plan and community resources to initiate referrals that address social determinants of health needs and follow-up to evaluate efficacy of the referral.


* Document patient progress in the electronic medical record.


* Participate in clinical team meetings as assigned.


* Work independently, receiving direction from manager or team leader for new or unprecedented situations.


* Provide in-services to care management team (and others) on community resources and federally funded programs that can assist chronically ill patients.

Minimum Qualifications


* Current, unrestricted license(s) issued by the Arizona Board of ...