MSW/LCSW Care Coordinator - Associates in Family Medicine

What do we stand for?

No matter why they come to see us, our patients want a convenient, wholehearted approach to health. That means a consistent experience they can count on and peace of mind, regardless of where they go or who they see. At AFM, we believe every body deserves exceptional care with every visit. We deliver compassion both in the office and out. We truly value our patients and their time. That’s why we actively listen to and talk with them, as well as our team members. And we not only offer comfort and clarity, but build honest, lasting patient relationships that put every mind at ease.

Our Mission

Empowering our staff to deliver compassionate, convenient healthcare and advocate well-being and peace of mind throughout your neighborhood – always.

Benefits & Pay Overview

AFM is proud to offer a comprehensive benefits package to eligible employees!

• Full-time Employees:

o Medical, Dental, Vision, and Long-Term Disability

• Part-time and Full-time Employees:

o Life Insurance (with AD&D), Flexible Spending Accounts, Short-Term Disability, Identity Protection, Pet Insurance, Employee Assistance Plans, and a generous 401(k)

• This is an exempt position with a salary of $51985.44 – $73195.20 per year guided by credentials, experience, and tenure at Associates in Family Medicine.

This position also has the unique benefit of working with a skilled, multidisciplinary team including clinic nursing, quality improvement personnel, providers, and pharmacists. Regular supervision offered and a chance to work with a fun, supportive, collaborative team of social work colleagues.

SUMMARY

This position will be an integral part of the organization working alongside other staff and providers to identify and reduce barriers to optimal patient-centered healthcare. They will promote optimum health through a variety of methods including: one-on-one conversations, connecting patient to community and internal resources and utilize data to identify patient needs as well as effectiveness of care management interventions in a team-based environment. This individual also demonstrates the ability to work effectively with others in a team-based environment through a variety of business situations. This person is professional, flexible, caring, and self-motivated.

DUTIES AND RESPONSIBILITIES:

• Implement systems of care that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute exacerbations.

• Support patients during transitions of care.

• Maintain required documentation for all care coordination activities. Collect required data and utilize data to adjust patient treatment plans.

• Establish rapport with patients and care teams to assist with transitions of care, assessing patient needs and goals, responding to changing patients’ needs, supporting patients’ self-management goals and working to align resources with patient and population needs.

• Provide patient education for improved medical management.

• Discuss Advanced Directives with patients and families.

• Address behavioral health needs to patients in the primary care office.

• Assess mental health needs and suicide risk in patients and provide safety planning to patients in crisis.

• Provide counseling and support for health behavior change.

• Employ motivational interviewing strategies and other evidence-based strategies to move patient closer to healthy behaviors.

• Utilize creative problem-solving skills to address unique barriers to health.

MISCELLANEOUS DUTIES, RESPONSIBILITIES, AND EXPECTATIONS

• Able to work the minimum number of hours required for the position which could include any operating hours of the clinics (potential for evening and weekend hours).

• Demonstrate knowledge of all AFM Policies.

• Ensure highest levels of patient satisfaction.

• Maintain the highest standard of personal ethics. Follow through with or transfer care for all services provided by AFM.

• Attend focus groups, committee meetings, all staff meetings, office huddles, and any other meetings as necessary.

EDUCATION and/or EXPERIENCE

Must have a Master’s in Social Work and be licensed; or equivalent combination of education and experience. LCSW or ability to obtain as soon as eligible preferred.

SKILLS and ABILITIES

• Knowledge of basic Microsoft Office Suite. EMR system familiarity preferred.

• Demonstrate the ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, and governmental regulations; the ability to write reports, business correspondence, and procedure manuals; and the ability to effectively present information and respond to questions from groups of staff, managers, patients, shareholders, and the general public.

• Demonstrate the ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals and the ability to calculate figures and amounts such as discounts, interest, and percentages.

• Demonstrate the ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form; solve practical problems and deal with a variety of concrete variables in situation where only limited standardization exists; and make sound business decisions based on available facts.

• Demonstrate the ability to work well with people and to remain calm and be effective in emergency situations.

• Possess sound judgment and be able to use a persuasive style of management when accomplishing things through people. Exhibit behavior which emphasizes quality, loyalty, and conscientiousness.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to stand; walk; use hands to finger, handle, or feel; and talk or hear. The employee is occasionally required to sit; reach with hands and arms; and stoop, kneel, crouch, or crawl. The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move more than 50 pounds. Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus.

WORK ENVIRONMENT

Medical Office setting. The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is occasionally exposed to risk of electrical shock and risk of radiation. The noise level in the work environment is usually moderate.

DISCLAIMER

This job description is not an all-inclusive statement of every duty and responsibility required of the employee. This job description may change over time. The pay scale for this position is based on performance with a minimum salary of $51985.44 and a maximum salary of $73195.20 per year guided by credentials, experience, and tenure at Associates in Family Medicine.