The Licensed Master Social Worker is responsible for a panel of geriatric patients and, in collaboration with other members of a multidisciplinary primary care team, helps patients meet their preventive, chronic, and acute care needs. They will engage patients and encourage them to take an active role in their health by providing them with the tools necessary to make healthy lifestyle choices and adopt lifelong healthy behaviors. This individual’s primary responsibilities center around establishing trusting, supportive, collaborative relationships with patients and their families. Our Guias build relationships with patients in a clinical setting and in the community by working alongside medical providers, nurses, other social workers, medical assistants, and a behavioral health specialist in a collaborative and empathetic team to improve patient outcomes. 

 

Responsibilities

• Actively engage a panel of assigned patients 
• Onboard patients to the care model and their medical/social care visits
• Function as a patient advocate by attending patient appointments when requested/needed two.
• Document relevant information about the patient’s health and healthcare experience and perform health risk and social needs assessments.
• Collaborate with a multidisciplinary team to care for a population of patients and monitor and track whether patients are up to date on preventive measures.
• Provide patient education on acute and chronic disease management.
• Provide guidance to patients and families.
• Establish healing relationships with patients and families.
• Learn to employ confidence-promoting techniques in patient communication and develop patient self-efficacy to better manage health.
• Communicate with patients in-person and by phone, video conference, and text messaging.
• Collaborate with other members of the multidisciplinary care team including but not limited to the Guia manager, Transitions of Care manager, Medicaid case managers, and medical assistants.
• Coach patients using an action-planning model based on motivational interviewing techniques.
• Assist with the coordination of care across the continuum, such as: scheduling appointments with providers, coordinating referrals, and sharing or transferring information with the patient’s internal and external care team.
• Participate broadly in the daily operations of a primary care practice, such as: Answering incoming phone calls and messages and ensuring general upkeep of the clinical space.
• Track patient enrollment and progression through care programs.
• Other duties as assigned by the Guia Manager

 

What You’ll Bring

 

Knowledge, Skills, and Abilities

• Experience in a customer service environment• Some clinical experience is a plus, such as LMSW or CHW-Instructor.
• LCSW Preferred.
• Experience working with geriatric population.
• Able to articulate mission in relation to patient satisfaction and patient outcomes.
• Compassionate, kind, and open-minded
• Teamwork experience.
• Proficient with a computer, mobile devices, medical devices, and Microsoft Office Suite
• Experience utilizing electronic medical records or social service referral management software.
• Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components.
• Ability to work independently and exercise sound judgment in interactions with providers, payors patients, and their families.
• Ability to communicate and effectively interact with people across cultures, ranges of ability, genders, ethnicities, and races.
• Effective oral and written communication skills
• Able to care for patients in-home, in-clinic, and remotely.
• Bilingual/Bicultural (English and Spanish)

  

Education, Experience, Licensure, or Certification Requirements

• Bachelor's degree (required)
• Master’s degree (preferred)

Equal Opportunity Employer