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Under the supervision of a licensed social work supervisor but with reasonable independence and AHP’s Clinical Manager of SW Care Management, the AHP (Accountable Health Partner) BSW provides consultation and social work services to AHP practice patients and their families. Responsibilities include intake psychosocial assessments, outreach, supportive, educational, concrete case management services to patients and families served by AHP practices. The BSW collaborates with AHP practice teams, most commonly the practice care manager, to assist patients who have identified social work needs. The BSW also provides consultation to health care providers regarding patients' care needs and/or community resources.
Job Responsibility:
Performs psychosocial assessments of patients and families referred by care managers and providers
Provides social work services and/or consultation in collaboration with care managers for patients with problems identified through psychosocial assessments
Collaborates with other practice care providers in development and implementation of interdisciplinary care plans
Coordinates referrals to and acts as liaison to community agencies regarding services to individual patients in collaboration with care managers
Provides internal and external systems advocacy as indicated in care plans of individual patient in collaboration with the care managers
Maintains current knowledge of community resources relevant to the AHP patient population
Provides appropriate assessment and intervention services for children and adults suspected of being victims of abuse, neglect and/or domestic violence
Participates in relevant training and educational opportunities designed to enhance knowledge and skills
Provides social work consultation to other care providers regarding patient problems and community services
Documents all social work activities in the patients' medical record in accordance with the relevant Social Work Division and AHP practice policies and procedures
As clinically indicated, makes outreach to patients' homes or community agencies to support implementation of care plans
Meets regularly with care management team and interprofessional staff to support team-based care in support of improving patient outcomes
Supports internal/family medicine practices in meeting quality measures as defined by the shared savings contracts
Participates in required activities of the Social Work Division and AHP including, but not limited to, timely completion of statistical reports/forms, time reporting and other AHP or Division forms, training programs and University Health Service reviews
Requirements:
BSW from an accredited social work program
3-5 years’ experience in a clinical setting (some ambulatory care experience preferred)
Excellent communication and team skills include ability to form strong collaborative interdisciplinary partnerships across care settings
Sound computer knowledge and skills include an aptitude for using health information technology to guide care management activities and functions
Ability to work independently and meet deadlines
Creativity and strong organizational skills
Valid NYS driver’s license includes access to reliable transportation that enables fulfillment of position’s travel requirements