Mount Sinai Careers

Social Worker – Care Management (High Risk – HARP)

New York, New York
Allied Health


Job Description

Strength Through Diversity

Ground breaking science. Advancing medicine. Healing made personal.

Department of Social Services (MSH)- Req Number:2317182


Job Title:  Social Worker – Care Management (High Risk – HARP)

  

Roles & Responsibilities:

Mount Sinai Health Partners (MSHP) is the management services organization developed to enhance the Health System’s implementation of population health initiatives, that is, programs of care that enhance the patient experience and health status, improve the health of patient populations and reduce utilization and healthcare costs. Population health initiatives particularly focus on preventive care. MSHP provides the infrastructure to support population health initiatives and includes services such as care coordination, information technology, workflow optimization, physician engagement and quality reporting. The Department of Social Work Services is positioned to take a lead role in the development of MSHP which will be providing transitional and care coordination services for a large group of individuals who have diverse insurances. 
The role of the Social Worker within the Health Home is to serve as a member of the interdisciplinary care team and to collaborate with this team and provide care coordination to high risk patients who meet eligibility criteria for the Health Home. The Social Worker will conduct biopsychosocial assessments with patients and family caregivers, identify barriers to seeking appropriate medical/behavioral health care and work with the team and patient/family caregivers to develop a care plan to overcome these barriers and increase adherence. (S)he will create linkages for patients with community organizations to facilitate adherence to the care plan and, provide ongoing phone contact and/or home visits and accompaniment to appointments to address medical and social needs in the community. The Social Worker may run, filter and analyze population management reports in Epic and other technology platforms and review data to identify preventive care/screening and disease management care gaps, high emergency department, and inpatient and specialty utilization and share this information with the care team to develop care coordination interventions. The Social Worker is responsible for educating patients/family caregivers on how to navigate the health system. For common patients, the Social Worker communicates with care coordinators in other MSHP programs to ensure collaborative and seamless work. The social worker will be responsible for management of High Risk and HARP (Health and Recovery Plan) patient populations in MSH campus.

 Requirements: 


New York State LMSW.
Bilingual (English/Spanish) required.
Exceptional skills in engaging patients/families and in assessment and coordination of resources within families and hospital and community networks for effective management of patient care.
Exceptional organizational, collaborative and psychosocial assessment and intervention skills.
Interest in being part of an innovative initiative to improve the quality of care by addressing barriers to primary and specialist care, preventable Emergency Department visits and hospital admissions/readmissions.
Hospital experience and experience with patients with chronic medical or behavioral health conditions in an ambulatory setting preferred.
Proficiency in MS Office. Ability to learn hospital ambulatory scheduling system and care coordination applications.



Strength Through Diversity


The Mount Sinai Health System believes that diversity is a driver for excellence. We share a common devotion to delivering exceptional patient care. Yet we’re as diverse as the city we call home- culturally, ethically, in outlook and lifestyle. When you join us, you become a part of Mount Sinai’s unrivaled record of achievement, education and advancement as we revolutionize medicine together.
 
We work hard to acquire and retain the best people, and to create a welcoming, nurturing work environment where you can develop professionally. We share the belief that all employees, regardless of job title or expertise, can make an impact on quality patient care. 

Explore more about this opportunity and how you can help us write a new chapter in our story! 

Who We Are

Over 38,000 employees strong, the mission of the Mount Sinai Health System is to provide compassionate patient care with seamless coordination and to advance medicine through unrivaled education, research, and outreach in the many diverse communities we serve.
 
Formed in September 2013, The Mount Sinai Health System combines the excellence of the Icahn School of Medicine at Mount Sinai with seven premier hospital campuses, including Mount Sinai Beth Israel, Mount Sinai Beth Israel Brooklyn, The Mount Sinai Hospital, Mount Sinai Queens, Mount Sinai West (formerly Mount Sinai Roosevelt), Mount Sinai St. Luke’s, and New York Eye and Ear Infirmary of Mount Sinai.
 
The Mount Sinai Health System is an equal opportunity employer. We promote recognition and respect for individual and cultural differences, and we work to make our employees feel valued and appreciated, whatever their race, gender, background, or sexual orientation. 

EOE Minorities/Women/Disabled/Veterans

 

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