Job Description

Job Summary and Essential Function
The Care Coordination MSW Social Worker works in collaboration with a multidisciplinary team of clinicians as part of the Care Coordination program to provide high quality outcomebased patientcentered care and address the social determinants of health to support safe transitions of care across the continuum for patients and families throughout Atlantic Health System.

Job Responsibilities along with a percentage of time performing duties
(Maximum of 10 bullet points)
60% Patient assessment referrals intervention
20% Documentation
10% Meetings program development
10% Collaboration with inside/outside agencies

3. Job Functions:

Support highcost/highrisk patients to address barriers to care and navigation challenges across the care continuum by prioritizing health and SDOH needs addressing gaps in internal and external resources and sustainable connections to medical homes and sustainable social supports to improve the patient experience achieve better health outcomes decrease avoidable cost and utilization and increase the utilization of preventative care and healthy behaviors to improve health.

Provide psychosocial assessment sustainable care transitions and structured support to help address social and economic barriers to positive health outcomes and empower patients to set and achieve their individualized health goals. Apply best practice interventions based upon care standards and referral and linkage to services to ensure behavioral and psychosocial needs are addressed including but not limited to: social needs financial stressors difficulty coping behavioral health concerns or substance misuse abuse and neglect interpersonal violence homelessness functional decline frequent ED visits or hospitalization need for longterm care planning etc.

Maintain best practices process systems and key performance metrics to provide effective outcomebased patientcentered care with a focus on culturallysensitive and inclusive interventions equitable access to care and reduction in health disparities. Conduct psychosocial assessment social determinants of health screening and referral and develop a plan of care in alignment with individual needs values and goals of the patient. Provide individual telephonic/virtual support and counseling to patients using appropriate therapeutic techniques and evidencebased theories to guide patients toward healthy coping selfmanagement and overall wellness. Maintain accurate and timely referral response assessment intervention and documentation according to department workflow and policy.

Ensure ongoing collaboration and communication with the larger interdisciplinary Care Coordination team AHS/ACO practices providers and care team members to comprehensively address evolving psychosocial needs medical needs and plan of care. Maintain a current knowledge base of community agencies and key contacts and assist with patient advocacy navigation and engagement with sustainable medical social insurance and benefit systems.

Regularly attend and actively participate in assigned intradisciplinary and interdisciplinary forums administrative meetings staff meetings supervisory sessions and inservice training. Provide consultative support for department community health workers through education training and one to one case oversight. Annually participate in a minimum of 3 educational programs on topics relevant to practice area.

Other tasks as required by manager director or leadership.

35 years in healthrelated field hospital experience preferred.
Strong knowledge of community resources and social service financial insurance and advocacy systems.
Familiarity with Epic preferred. Exceptional organizational and time management skills with the ability to multitask problemsolve and balance and deliver results in a program with multiple projects programs and priorities.

Strong clinical interpersonal and analytical skills with clear verbal telephonic and written communication.

Ability to function within an interdisciplinary team and develop and enhance collaborations with local community agencies and organizations.

Ability to navigate EMR and databases with demonstrated ability including EMR documentation standards Microsoft Office suite and metrics/outcome reporting.

Strong interpersonal and communication skills problem solving ability to work with diverse populations compassionate service delivery. Bilingual a plus.

Masters Degree in Social Work from an accredited school of social work required.

Current LSW license in the State of New Jersey in good standing with the NJ Board of Social Work Examiners.

Behavioral Health background preferred.

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