We’re unique. You should be, too.We’re changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded Is your work ethic and ambition off the charts Do you inspire others with your kindness and joy We’re different than most primary care providers. We’re rapidly expanding and we need great people to join our team.The Social Complex Care Manager, SW, is a Community Social Worker that works closely with the PCP, Medical Specialists and other members of the Complex Care team such as Post Hospital Care Coordinators, Post Hospital Care Manager, Hospital Care Managers, and Intensive Community Case Managers. The incumbent in this role is responsible for providing psychosocial assessment, social case work and linkage to community resources for complex patients who have chronic, life threatening or altering diseases and disorders and may be at high risk for hospitalization. The incumbent in this profile advocates for services and resources for the underprivileged and victims of abuse, neglect, or other difficult personal situations to help them maintain an optimum level of health and prevent hospital arrivals. Community Social Workers will adhere to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance, and policies and procedures as defined by industry standards and the enterprise. The success of this role is determined by the impact social needs management has on patients with complex social needs on preventing unnecessary hospital arrivals.ESSENTIAL JOB DUTIES/RESPONSIBILITIES:Needs Identification and assessment:Conducts timely and appropriate assessment and needs identification, prioritizing patients on the Intensive Community Care (ICC) program, PCP’s High Priority Patients (HPP) and Top 40 patient lists. Assesses the patients for psychosocial, financial, family issues, palliative care/end of life issues, home safety, etc. that negatively impact their health outcomes and at risk for hospitalization.Communicates with PCPs and interdisciplinary Care Team in order to support and advise concerning social needs and resources available in community resource database.Medicaid and other benefit eligibility assessments:Conducts appropriate assessment of needs and financial benefit eligibility.Assesses patients for Medicaid criteria and assists with application process as needed.Assists patients to obtain community resources/services as appropriate, e.g. meals, medications, housing, daycare, HHA and other SDoH needs as identified.Resource coordination and prevention: Serves as care coordinator linking patients with internal and external resources, prioritizing complex patients whose needs can lead to unnecessary hospital arrivals.Educates center staff, other members of the care team, patients and caregivers on how to access community resources as identified by the patients SDoH Wellness Screening.Works with patient, family, and interdisciplinary care team to facilitate applications for higher level of care.Maintains an accurate repository of social wellness tools and resources for the care team’s awareness and utilization with patients in need.Communication:Maintains communication with interdisciplinary team members by attending appropriate meetings (i.e. weekly Super Huddles and Hospital and Community Care Team (HCT) meeting.)Provides consultation in an integrated health care environment regarding social determinants of health and community resources.Timely and accurate documentation:Maintains timely, accurate, thorough and appropriate documentation/reports per company policies and procedures. Initial psychosocial assessments will be completed within 48 hours. All follow- up visits, phone calls and collaborative contacts will be documented within 24 hours. Assures documentation meets billing guidelines.Additional duties may include:Works closely with the Complex Care Team to secure the appropriate level of care post hospital/SNF discharge. Further interventions may be conducted in the center, by phone call or patient’s home.Performs other duties as assigned and modified at manager’s discretion.KNOWLEDGE, SKILLS AND ABILITIES:Keen business acuity and acumenFull knowledge and understanding of general Social Worker functions, practices, processes, procedures and techniquesKnowledge of social services documentation procedures and standardsKnowledge of community health services and social services support agencies and networksKnowledge of normative changes (e.g., sensory, cognitive, psychosocial) associated with aging for high-risk patientsKnowledge of advance care planning and palliative care, and related skill in addressing advance care planningEthical practice behavior consistent with ChenMed policies and professional standardSkill in psychosocial interventions with challenged caregivers/family systems of high-risk patientsAppropriate utilization of community-based resourcesTeamwork skills in care coordination with patients, family systems, staff, and external providersAbility to work autonomously is requiredAbility to monitor, assess and record patients’ progress and adjust accordinglyAbility to communicate technical information to non-technical personnel, and with patients and/or their family systemsStrong interpersonal, communication and critical thinking skills and the ability to work effectively with a wide range of constituencies in a diverse communityDemonstrated ability to provide care effectively and sensitively to people from different cultural groupsAbility to create a collaborative relationship to maximize the patient’s/family’s ability to make informed decisionsProficiency in written communication: documentation is clear, concise, accurate, provides meaningful communication and is consistent with company policy and regulatory requirementsProficiency in technology, including the utilization of Electronic Medical Record platforms for care coordinationProficient in Microsoft Office Suite products including Word, Excel, PowerPoint and Outlook, plus a variety of other word-processing, spreadsheet, database, e-mail and presentation softwareAbility and willingness to travel locally, regionally and nationwide up to 10% of the timeSpoken and written fluency in EnglishThis job requires use and exercise of independent judgmentEDUCATION AND EXPERIENCE CRITERIA:BS degree in Social Work requiredMaster’s Degree of Social Work (MSW) preferredA minimum of 2 years’ work experience in social work, case management, and/or discharge planning experience requiredA minimum of 2 years’ experience in a primary care setting preferredState Licensure at a Master’s Level is preferred but may be required (dependent on state)If applicable, incumbent must be compliant with the mandatory laws of state licensure at the Master’s level.Spanish Bilingual PreferredWe’re ChenMed and we’re transforming healthcare for seniors and changing America’s healthcare for the better. Family-owned and physician-led, our unique approach allows us to improve the health and well-being of the populations we serve. We’re growing rapidly as we seek to rescue more and more seniors from inadequate health care. ChenMed is changing lives for the people we serve and the people we hire. With great compensation, comprehensive benefits, career development and advancement opportunities and so much more, our employees enjoy great work-life balance and opportunities to grow. Join our team who make a difference in people’s lives every single day.Current Employee apply HERECurrent Contingent Worker please see job aid HERE to apply#LI-Hybrid