The Outpatient Care Manager, Social Worker (OP CM SW) is responsible for providing Social Work and care management services to out-patients and their families as directed by the policies and procedures of the entity and Outpatient Care Management Department. The OP CM SW provides professionally established methods of assessing a patient's unique bio-psychosocial status, assists patients and families in resolving problem areas, and connects them with appropriate community resources and services.
Responsible for the psychosocial component of patient care as it relates to medical stability and wellness, the OP CM SW collaborates with both health care and community partners to address social determinants of health and promote self-management of care needs. The OP CM SW also collaborates with the Outpatient Care Manager RN, and other members of the Care Management team as needed to address the social needs of the medically complex patient.
The Outpatient Social Worker Care Manager works a hybrid schedule and may need to see patients in an office setting as needed.
Provides assessment, care planning and intervention to patients and caregivers, including psychosocial and resource evaluation and planning, advocacy, as well as crisis intervention as appropriate.
Follows the care management process including patient identification, engagement/enrollment, assessment, care planning, and case closure
Manages a caseload of patients and prioritizes new referrals with patients who require follow up to complete care plan goals
Appropriately refers to other care manager disciplines within the department to meet the patient's holistic health care needs.
Appropriately delegates tasks to the Care Manager Outreach Coordinator (CMOC) as needed
Provides counseling directed toward helping patients/caregivers cope with and understand the relationship between physical functioning, illness and the consequent social/emotional impact and adjustments required.
Practices motivational interviewing skills and teach-back skills when interviewing/assessment of patients
Consult with providers, nurses and other members of the health care team to facilitate interdisciplinary care and address effective continuum of care coordination.
Investigates insurance benefits as well as community resources to provide and facilitate appropriate referrals based on patient/caregiver agreement.
Organizes individual patient care meetings with internal and as necessary, external multidisciplinary team members and the patient/caregiver to evaluate progress and to identify and resolve problems that may interfere with a positive patient outcome.
Provides patient/caregiver and/or care team education as needed as it relates to government mandates/laws.
Proactively collaborates with patient/caregiver, care team members, and community partners as necessary to address bio-psychosocial needs to ensure efficient and effective continuity of care, utilization of resources and to avoid unnecessary hospitalizations.
Ensures accurate clinical and patient care documentation in patient charts, completes reports and other requested/required patient documentation as needed, and maintains required statistical documentation for the department's management information system.
Functions autonomously under the Organization and Departmental policies and procedures and in compliance with the NASW Code of Ethics.
Acts as a liaison to community agencies, health institutions, etc., to address systems issues affecting patient outcomes by serving, as able, in community groups and organizations.
Demonstrates competency in the assessment, range of treatment, knowledge of growth and development, and communication appropriate to the age of the patient treated.
Compliant with annual network or department competencies focusing on health coaching patients on self-management tools related to chronic illnesses and appropriate health coaching.
Maintain timely, accurate, complete, and consistent documentation appropriate to role in the electronic medical record.
Maintains expertise in telehealth procedures, participates in staff meetings, participates in network and/or department committees or special projects as assigned.
Participates in peer educational presentations.
Supports Network and department goals and objectives.
Demonstrates financial responsibility and accountability through the effective and efficient use of resources in daily procedures, processes, and practices.
Complies with Network and departmental policies regarding attendance and dress code.
Participates in quality and/or performance improvement projects/pilots.
Participates in orientation of new Care Management staff as assigned.
PHYSICAL AND SENSORY REQUIREMENTS:
Sitting for one to two hours at a time, stand for two to three hours at a time, walk on all surfaces for up to five hours per day, and climb stairs. Must be capable of driving a car. Occasionally firmly grasp, twist and turn objects with hands and fingers. May be required to lift, carry, push, and/or pull objects weighing up to 25 pounds. Occasionally stoops, bends, squats, kneels and reaches above shoulder level. Must have the ability to hear as it relates to normal conversations and high and low frequencies and to see as it relates to general and peripheral vision. Must have the ability to touch as related to telephone and computer keyboard.
EDUCATION:
Master’s degree in social work from an educational institution accredited by the National Council on Social Work Education (NCSWE) preferred. May have bachelor’s degree in social work with minimum 5 years medical Social Work experience.
LICENSURE / CERTIFICATION:
State licensure for MSW in PA preferred.
State licensure for MSW in NJ required.
State certification for BSW in NJ required.
TRAINING AND EXPERIENCE:
MSW with minimum of two (2) years' experience in medical social work case management or other experience as related to site of service preferred or as above.
Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!!
Founded in 1872, St. Luke’s University Health Network (SLUHN) is a fully integrated, regional, non-profit network of more than 23,000 employees providing services at 16 campuses and 350+ outpatient sites. With annual net revenue of $4 billion, the Network’s service area includes 11 counties in two states: Lehigh, Northampton, Berks, Bucks, Carbon, Montgomery, Monroe, Schuylkill and Luzerne counties in Pennsylvania and Warren and Hunterdon counties in New Jersey. St. Luke’s hospitals operate the largest network of trauma centers in Pennsylvania, with the Bethlehem Campus being home to St. Luke’s Children’s Hospital. Dedicated to advancing medical education, St. Luke’s is the preeminent teaching hospital in central-eastern Pennsylvania. In partnership with Temple University, the Network established the Lehigh Valley’s first and only four-year medical school campus. It also operates the nation’s longest continuously operating School of Nursing, established in 1884, and over 50 fully accredited graduate medical educational programs with more than 500 residents and fellows. In 2022, St. Luke’s, a member of the Children’s Hospital Association, opened the Lehigh Valley’s first and only free-standing facility dedicated entirely to kids. SLUHN is the only Lehigh Valley-based health care system to earn Medicare’s five-star ratings (the highest) for quality, efficiency and patient satisfaction. It is both a Leapfrog Group and Healthgrades Top Hospital and a Newsweek World’s Best Hospital. The Network’s flagship University Hospital has earned the 100 Top Major Teaching Hospital designation from Premier 13 times total and eleven years in a row, including in 2023 when it was identified as THE #4 TEACHING HOSPITAL IN THE COUNTRY.
