COMMUNITY BASED SOCIAL WORK CARE COORDINATOR Job Number: 00122056
Job Posting : Nov 9, 2018, 9:33:49 PM Closing Date : Ongoing Full-time
Collective Bargaining Unit: SEIU Local 73 Posting Salary: $31.583 HOURLY
Organization: Health and Hospital Systems
The Community Based Social Work Care Coordinator (CBSWCC) supports the provision of care coordination in a manner that recognizes the Enrollee and the medical home care teams as essential partners in the Enrollee's care. These services are offered at the patient's home, physician office, and/or other health care facilities. If it is determined the Enrollees care is medically complex the CBSWCC collaborates with a nurse in the provision care coordination. Completes assessments of unmet health care needs and/or the presence of social determinants that impact the provision of care. Collaborates with Enrollee and medical home care team to develop and implement a care plan that mitigates barriers and links patients to appropriate resources. The CBSWCC works across sites of care and with multiple disciplines to achieve the desired outcomes for the Enrollees. Supervises the activities of the assigned Community Health Worker (CHW). (multiple vacancies)
Uses all available information sources to support care coordination activities-this may include portals, electronic medical records, claims data, plan information, utilization management information, and Milliman Care Guidelines (MCG).
Completes screenings, assessments and care plan in accordance with contractual requirements and Care Coordination policy and procedure.
Integrates information from claims review, notes, screenings, assessments and Medical Home teams in care plan.
Tracks patient progress regarding goal achievement on the care plan.
Updates documents based on Enrollee progress, changes in priorities, changes in health status or new information.
Supports care coordination referrals from multiple sources including Enrollee request, plan referrals, medical home referrals, grievances, data reports or changes in risk score.
Provides relevant education, counseling and support to assist member with the achievement of goals.
Collaborates with Nurse Care Coordinators on patients with multiple co-morbidities, frequent hospitalizations or inappropriate Emergency Department (ED) visits.
Interfaces with Medical Home team and Enrollee at prescribed or agreed upon intervals.
Participates in Interdisciplinary Care Teams, presents own patients, and provides guidance on others not directly managed.
Conducts face to face visits on members with high or moderate risk stratifications on a quarterly basis.
Conducts monthly outreach for high risk patients who are stable, more often for patients undergoing a transition or a change in treatment. Updates medical home team on status.
Completes all required trainings, workshops, etc. within the required timeframe.
Collaborates with medical home assignments to identify resources and process for effective communication.
Conducts outreach to Case Management Department at hospital when Enrollees are admitted.
Meets established case deadlines.
Travels to the home of the Enrollees or their sites of care.
Performs other duties as assigned.
Licensed Clinical Social Worker (LCSW) or Licensed Clinical Professional Counselor (LCPC) in the State of Illinois (must provide proof at time of interview)
Three (3) years of health care work experience (is required)
Prior care management work experience in a social service agency, physician group, hospital or Emergency Department setting (is required)
Valid Driver's license and mandatory vehicle insurance or other means of transportation (must provide proof at time of interview)
Knowledge, Skills, Abilities and Other Characteristics
Knowledge of Microsoft Office products
Effectively communicates care coordination benefits to Enrollees, Medical Home Teams and hospital based staff
Collaborates effectively with team members
Ability to work at a fast-paced
Ability to effectively prioritizes tasks
Ability to work independently
Ability to probe to get to underlying behaviors or Enrollee assumptions that are driving care coordination results
Ability to communicate non-judgmental attitude
Medical, Dental, and Vision Coverage
Basic Term Life Insurance
Deferred Compensation Program
Paid Holidays, Vacation, and Sick Time
You may also qualify for the Public Service Loan Forgiveness Program (PSLF)
When applying for employment with the Cook County Health & Hospitals System, preference is given to honorably discharged Veterans who have served in the Armed Forces of the United States for not less than 6 months of continuous service
To take advantage of this preference a Veteran must :
Meet the minimum qualifications for the position.
Identify self as a Veteran on the employment application by answering yes to the question by answering yes to the question,
The Cook County Health & Hospitals System’s mission is to deliver integrated health services with dignity and respect regardless of a patient’s ability to pay; foster partnerships with other health providers and communities to enhance the health of the public; and advocate for policies that promote the physical, mental and social wellbeing of the people of Cook County. CCHHS is comprised of two hospitals, John H. Stroger, Jr. Hospital and Provident Hospital, a robust network of more than a dozen community health centers, the Ruth M. Rothstein CORE Center, the Community Triage Center, the Cook County Department of Public Health, Cermak Health Services, which provides health care to individuals at the Cook County Jail and the Juvenile Temporary Detention Center, and CountyCare, a Medicaid managed care health plan.The system cares for more than 300,000 patients each year and its physicians are experts in their fields, committed to providing their patients with comprehensive, compassionate and cutting-edge care. Today, CCHHS is transforming the provision of health care in Cook County by promoting community-based primary and preventive care, growing an innovative, collaborative health plan and enhancing the patient experience.