Travel Social Work - Social Worker
Summit, New Jersey
Overlook Medical Center

Support high-cost/high-risk 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 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.

Maintain best practices, process systems, and key performance metrics to provide effective outcome-based, patient-centered care with a focus on culturally-sensitive and inclusive interventions, equitable access to care, and reduction in health disparities.

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 in-service 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.

Strong knowledge of community resources and social service, financial, insurance, and advocacy systems.

Familiarity with Epic preferred.

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.