RN / LCSW

Primary Functions :

• Responsible for patient outreach, assessment, disease management, and care coordination to patients with high rates of medical and behavioral health utilization and / or psychosocial vulnerability
• Assess patients through telephonic and eventually face to face encounters
• Builds a collaborative relationship with patients and their identified support system to encourage care participation and improve self-management of needs
• Utilize motivational interviewing to identify barriers and facilitate care plan compliance
• Effectively educate patients about healthcare delivery, plan benefits and a variety of topics related to health, and community resources
• Coordinates timely and appropriate implementation of assessments, care plans, and interventions for the identified patient population
• Provide medication reconciliation and support ongoing adherence
• Provide transitional care management
• Identify and helps to align patient care and community resources to prevent hospital readmissions and Emergency Department visits
• Document all activity in the documentation systems relevant to the role
• Collaborate with the care team to achieve high-quality, low-cost outcomes for patients.
• Interface and maintain positive relationships with key providers in the local hospitals, community practices, and organizations to ensure proper patient engagement and follow up
• Achieve established productivity targets
• Maintain compliance with the organization policies and procedures
• Demonstrate the ability to adapt, innovate and lead in a fast-paced environment, where change is common
• Passionate about making a difference in individual’s lives
• Other duties as assigned

Qualifications :

Requires a Master’s in Social Work

Must have a current full licensure as a LCSW by the NC Social work Certification and Licensure Board

Two years post master’s clinical experience is required

Medical Social Work experience strongly preferred

Knowledge of care management and quality principles are preferred

Requires the ability to maintain confidentiality

Must be able to interact with individuals of all cultures and level of authority

Additional skills required :

Excellent and effective written and oral communication skills.

Proficiency in Microsoft Office Outlook, Word, Excel, PowerPoint use and e-mail communication.

Ability to communicate clearly and succinctly.

Dependable, manages time well; efficient and organized.

Must be able to interact with individuals of all cultures and levels of authority.

Requires the ability to maintain confidentiality.

Benefits :

401(k)

Health, Dental and Vision insurance

Employee assistance program

AFLAC

Paid time off

Equal Opportunity Employer

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