JOB SUMMARY

Responsible for assessing and addressing the psychosocial, social, and community-resource needs of patients, with a primary focus on Medicare HMO/Medicare Advantage members assigned to or receiving care through the clinic. The role supports the proactive management of this population by identifying social barriers to care, coordinating community and behavioral health resources, conducting outreach, and collaborating with the clinical and care management teams to improve access, continuity of care, and completion of the established care plan. While Medicare HMO members are the primary population managed by this position, the Social Worker also provides support to other patients presenting to the clinic who have identified social, behavioral, psychosocial, or community-resource needs, based on clinical and operational priorities.

ESSENTIAL FUNCTIONS

• Serves as the primary social work resource for the management and support of Medicare HMO/Medicare Advantage members, including assigned lives and other identified high-risk or high-need members.
• Conducts proactive outreach to Medicare HMO members based on established priorities, care gaps, utilization patterns, referrals, and identified social needs.
• Evaluates psychosocial needs and social determinants of health and communicates findings and recommended interventions to the interdisciplinary care team.
• Develops and follows individualized social work interventions as part of the patient's overall care plan, monitoring progress through completion or appropriate closure.
• Identifies barriers that may affect the patient's ability to access or comply with care, including transportation, financial limitations, caregiver support, housing, food insecurity, behavioral health needs, and access to community services, and coordinates appropriate interventions.
• Coordinates access to community resources, social services, government programs, behavioral health services, and other support services based on identifies patient needs.
• Supports Medicare HMO initiatives aimed at improving care coordination, preventive care completion, continuity of care, and appropriate healthcare utilization, including follow-up when social work intervention is indicated.
• Collaborate closely with physicians, clinicians, nursing staff, care management, operations, and other members of the interdisciplinary team to address patient needs and facilitate continuity of care
• Provides social work to other patients presenting to the clinic, regardless of payer, when psychosocial or social needs are identified and intervention is appropriate
• Documents assessments, interventions, referrals, outreach attempts, outcomes, and follow-up activities in the designated clinical or care management system and meets established caseload, outreach, documentation, and productivity expectations.

EDUCATION

EXPERIENCE

• Bachelor’s Degree in Social Work with at least one (1) 
  year of clinical experience, preferably in areas related to health such as primary care, hospitals, community or 
  hospice.
• Current/ valid license Puerto Rico Social Worker without restrictions. Member of College of Social Workers of Puerto Rico.

LICENSES AND CERTIFICATIONS

COMPETENCIES