Mount Sinai Careers
Social Worker – Care Management (High Risk – HARP)
Strength Through Diversity
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Department of Social Services (MSH)- Req Number:2317182
Job Title: Social Worker – Care Management (High Risk – HARP)
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.
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