GENERAL OVERVIEW: This job collaborates with the interdisciplinary team of providers, clinicians, health plans, and external partners while advocating for patients and families/caregivers to coordinate care across the continuum. The incumbent is an integral member of the Care Management team that works to improve the quality of care, patient experience, and the health of populations and individuals by focusing on the social determinants of health impacting wellness. ESSENTIAL RESPONSIBILITIES: Contributes to and/or completes initial and ongoing comprehensive assessment. Provides interventions and implements recommendations after engaging patients and their caregivers/families. Focuses on the individual's risk related to social determinants of health to assure successful coordination of care across the continuum. (30%) Collaborates to provide the safest transition plan for assigned patients (Inpatient/Observation/ED) to ensure a timely discharge and provide appropriate connection with post-discharge care providers and community-based resources. (25%) Educates patient, family/caregiver and physician regarding most appropriate level of care post discharge and how to access community support. Advocates for the patient, family/caregiver through effectively communicating with interdisciplinary team members, payers and post-acute partners to assure the safest transition. (20%) Serves as a resource to provide counseling and intervention related to treatment decisions and end-of-life issues. Drives collaborative conversations to establish goals of care. Provides crisis interventions in cases involving Child Abuse and Neglect, Domestic Violence, Adult and Older Adult Abuse, Institutional Abuse Sexual Assault, Mental Health Disorders, Substance Use Disorders, and Identification of a Surrogate Decision Maker/Guardianship. (15%) Promotes individual professional growth and development through certification, mentoring/precepting, and/or participation on department/hospital/system committees. (5%) Supports Department based goals that contribute to the success of the organization. (5%) Other duties as assigned. QUALIFICATIONS: Minimum Master's degree in Social Work (Incumbents in the role on or before 4/21/2025 have 6 months from hire date to obtain) Experience in a hospital or health care setting LSW and/or LCSW required (Incumbents in the role on or before 04/21/2025 have 12 months from hire date to obtain) Act 34 Criminal Background Clearance Certificate Act 33 Child Abuse Clearance Certificate Act 73 FBI Fingerprinting Criminal Background Clearance Certificate. Preferred None Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements. Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.
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