Job Summary:

Oversees care management and coordination of activities for patients of the healthcare system. Develops and monitors care management coordination processes and support of patients for multidisciplinary teams. Identifies high acuity patient population, high utilizers, and high readmission risk patients.

Job Responsibilities:

• Works with all clinical teams as a resource on care management of all patients of the healthcare system to ensure care completion in and out of the hospital setting.

• Involves the patients in activities to improve their health (patient engagement); educates patients about self management tasks they can undertake to gain greater control of their health status.

• Manages assigned panel of chronic care, high acuity, and readmission risk patients.

• Develops relationship with patient as an integral member of the team.

• Provides follow-up contact with patient as indicated to ensure compliance with recommendations, medications, lab, x-ray, specialist visits, Primary Care Physicians (PCP) visits, dietitians, and durable medical equipment (DME), etc.

• Manages many aspects of the patient's care: referral to specialists, hospitalizations, emergency department (ED) visits, ancillary testing, nd other enabling services.

• Available to provide telephone advice per protocol, handles urgent and emergent calls.

• Anticipates the needs of this patient population seeing that necessary documentation and planning is completed for patient continuity of care.

• Works with patient and patient's care team to coordinate change readiness, needs assessment, and develops an individualized treatment care plan.

• Assists patient in setting SMART goals for self-management, teaches them how to do self-management tasks, and reports abnormal finding to their physician team.

• Collaborates with the patient, physician, and other care team members in assessing the patient's progress toward health care goals.

• Assesses barriers when patient has not met treatment goals, is not following treatment plan of care, or has not kept important appointments.

• Oversees the development, procurement, and adoption of patient self-management educational resources used by the clinical teams.

• Collaborates with payer care managers for additional services when appropriate.

• Develops a list of medical supplies and community resources available to patients and maintains collegial relationships with the entities used most frequently.

• Works with consulting physicians, hospitals, ED, and other frequently used healthcare sources to clarify roles and develop effective, efficient, and timely communication between PCPs and these entities.

• Coordinates consults, referrals, hospital/ED, and community resource follow-up and tracking processes for the health system working to have clerical component done by appropriate clerical staff.

• Develops workflows and protocols within the healthcare system that ensure the ED, hospital, and community resource follow-up.

• Facilitates clinical follow-up with patients when indicated.

• May make home/community visits when deemed applicable to assist with social determinants of care and resolution to social barriers.

Skills and Attributes:

• Requires critical thinking skills and decisive judgment.

• Works under general supervision.

• Must be able to work in a stressful environment and take appropriate action.

• Applies more advanced skills and knowledge in the area of specialization.

Position Requirements:

Work Experience

• A minimum of 1 year relevant experience preferred

Education

• Bachelor's degree or higher in Social Work required upon hire

Additional Education Information

• None

Licensure/Certification/Registration

• LSW - Licensed Social Worker in the State of Kentucky required upon hire OR

• LCSW - Licensed Clinical Social Worker in the State of Kentucky required upon hire OR

• CSW - Certified Social Worker in the State of Kentucky required upon hire

Organizational Responsibilities:

• Supports Owensboro Health’s Mission, Vision, Core Commitments, and business interests.  Adheres to all organizational policies and procedures. Executes all tasks and behaves in a manner consistent with a culture of compliance, safety and a high reliability organization.

Additional Job Information:

• This job description describes the general nature and level of work required by the position. It is not intended to be an all-inclusive list of qualifications, skills, duties, responsibilities or working conditions of the job. Specific duties and responsibilities consistent with the general nature and level of work described may vary by department and additional related duties may be assigned as needed. Some duties listed may not apply to all employees with this job description. 

• The job description is subject to change with or without notice, and Management reserves the right to add, modify or remove any qualification or duty. Nothing in this job description changes the existing at-will employment relationship between the Organization and the employee occupying the position.

Standard ADA Settings:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Physical Demands: (Office Environment)

Standing: 50%

Walking: 50%

Sitting: 75%

Lifting 0-25 lbs: 25%

Lifting 25-75 lbs: 0%

Lifting over 75 lbs: 0%

Carrying 0-25 lbs: 25%

Carrying 25-75 lbs: 0%

Carrying over 75 lbs: 0%

Pushing/Pulling 0-25 lbs: 25%

Pushing/Pulling 25-75 lbs: 0%

Pushing/Pulling over 75 lbs: 0%

Climbing: 25%

Bending/Stooping: 25%

Kneeling: 25%

Crouching/Crawling: 25%

Reaching: 50%

Talking: 75%

Hearing: 50%

Repetitive Foot/Leg Movements: 0%

Repetitive Hand/Arm Movements: 75%

Keyboard Data Entry: 75%

Running: 0%

Vision: Depth Perception: 75%

Vision: Distinguish Color: 75%

Vision: Seeing Far: 75%

Vision: Seeing Near: 75%

Hazardous Drug Risk Exposure: Low Risk

Owensboro Health Core Commitments

INTEGRITY - We conduct ourselves with a high level of responsibility, reliability and honesty because we take seriously the trust of our patients and coworkers.

RESPECT - We value and accept the unique talents and contributions of every patient, customer and team member in the Owensboro Health community.

TEAMWORK - We build a spirit of connectivity and fellowship by striving together to overcome obstacles, surpass goals, celebrate accomplishments and plan the future.

INNOVATION - We foster original ideas and creative solutions that improve our daily work and promote the mission of Owensboro Health.

SERVICE - We focus on service to patients, customers and team members by anticipating their needs, thoughtfully meeting those needs and continually improving the quality of everything we do.

EXCELLENCE - We reach beyond basic expectations to expand our knowledge and awareness, produce exceptional work and provide outstanding service.