Northern Light Health Department: Community Care Team Position is located: Ellsworth Family PracticeWork Type: Full TimeHours Per Week: 40.00Work Schedule: 8:00 AM to 4:30 PMSummary:Serves in an expanded role to collaborate with patients, Primary Care Providers, practice teams, and all community agencies, to provide a model of care that ensures the delivery of quality, efficient, and cost-effective healthcare services. Assesses patient needs from a strengths based, person in environment manner, to design and implement, coordinated intervention plans that monitor and evaluate options and services that aid towards meeting the shared goal of optimizing the patient’s physical and bio-psycho-social-spiritual health status and lowering avoidable costs associated with less than optimal health and/or misuse/overuse of medical/community based services. The Social Worker works collaboratively within Beacon Health’s care coordination program and all care team members to ensure patient needs are met and care delivery is coordinated, and not duplicated, across the healthcare continuum. The expertise of the Social Worker is sought to assess and intervene with bio-psycho-social-spiritual barriers to patient’s engaging with the healthcare system in a manner that promotes optimal health. Utilizes evidence based shared decision making models, motivational interviewing, and other evidence based interventions to encourage positive behavior change in order to assist patients to achieve their highest level of function.Responsibilities: Conduct assessments in a variety of settings, including, but not limited to PCP offices, patient homes, hospital, or other community based settings as deemed appropriate for each individual patient assigned. Assists to develop coordinated care plans for patients with complex medical and/or behavioral health needs. Fosters a team approach by working collaboratively with all practice and community based team members. Coordinates referrals between and among physical and behavioral providers to necessary and appropriate community resources to assist patients to meet their goals and improve functioning. Ensures appropriate clinical information is shared timely with peers, providers and outside agencies while adhering to system privacy standards. Works closely with payers to appropriately apply member benefits and serve as a resource to the member and healthcare team. Maintains required documentation for all patient care activities. Collects required information and utilizes it to adjust the treatment plan when indicated. Adheres to EMHS’ and Beacon Health’s policies regarding member confidentiality. Incorporates excellent written, verbal, and listening communication skills, positive relationship building skills, and critical analysis skills into social work practice. Develop collaborative relationships with community based agencies to understand and disseminate program and service eligibility, thus allowing for efficient use of referral systems aimed at improving care. Utilizes appropriate conflict resolution, assertiveness, advocacy, brokerage, negotiation, and collaboration skills in facilitating patients’ movement throughout the health care continuum. Participates in all required training and supervision to maintain State of Maine Social Work licensure.Other Information:see above. Competencies and Skills
2+ years of relative work experience required.
Achieves Results: Sets high standards for their own outcomes and seizes opportunities to engage others towards objectives. Consistently moves forward with direct actions in order to attain or exceed objectives. Manages their own time effectively to accomplish assigned tasks. Successfully prioritizes multiple projects and duties as needed.
Behaves with Integrity and Builds Trust: Acts consistently in line with the core values, commitments and rules of conduct. Leads by example and tells the truth. Does what they say they will, when and how they say they will, or communicates an alternate plan.
Cultivates Respect: Treats others fairly, embraces and values differences, and contributes to a culture of diversity, inclusion, empowerment and cooperation.
Demonstrates Adaptability: Learns quickly when facing a new problem or unfamiliar task; is flexible in their approach with changing priorities and ambiguity. Manages change effectively and does not give up during adversity. Capable of changing one's behavioral style and/or views in order to attain a goal. Absorbs new information readily and puts it into practice effectively.
Demonstrates Emotional Intelligence: Exhibits a high level of self-awareness, self-management, other awareness and relationship management. Conducts themselves in an empathic, appropriate way, with a sense of humor and stimulates a collaborative work environment. Is respectful of the attitudes, feelings, or circumstances of others and aware of the influence of their own behavior on them. Is aware of relevant social, political, system, and professional trends and developments and uses this information for the organization's benefit.
Effectively Communicates: Listens, speaks and writes appropriately, using clear language. Communication methods are fitting to the message(s), audience, and situation and follow-ups are regular and timely. Shows that important (non-) verbal information is absorbed and understood and asks further questions to clarify when necessary. Expresses ideas and views clearly to others and has ability to adjust use of language to the audiences' level.
Exercises Sound Judgment & Decision Making: Understands and processes complex information, which allows for appropriate and accountable conclusions. Does not react too quickly or slowly. Balances facts, goals, and potential approaches taking the appropriate criteria into account. Makes active decisions and commits oneself by communicating confidently and respectfully.
Fosters Accountability: Creates and participates in a work environment where people hold themselves and others accountable for processes, results and behaviors. Takes appropriate ownership not only of successes but also mistakes and works to correct them in a timely manner. Demonstrates understanding that we all work as a team and the quality and timeliness of work impacts everyone involved.
Influences and Inspires: Builds enthusiasm and commitment among others to move in a desired direction and models it personally. Creates a compelling vision of success that motivates workplace initiative and energizes others to follow. Provides direction and guidance to encourage cooperation between team members in order to attain an objective. Has the ability to appropriately influence others' actions and decisions with and without express authority.
Practices Compassion: Exhibits genuine care for people and is available and ready to help; displays a deep awareness of and strong willingness to relieve the suffering of others.
Provides Patient-Centered Care: Demonstrates understanding of patient care quality and service as organizational priority. Proactively supports change to improve patient experience and results. Exhibits the ability and willingness to find out what the patient wants and needs and to act accordingly, taking the organizational and outside resources into account. Cooperates, collaborates, communicates, and integrates care within and between teams to ensure that care is continuous and reliable.
Serves Others: Strives to understand, meet and exceed the expectations and requirements of internal and external customers which may include the people and communities in our service areas. Develops and maintains relationships, alliances and coalitions within and outside the organization and leverages them in order to obtain information, support, and promote cooperation and collaboration.
Credentials
Required Licensed Social Worker (LSW, LCSW, LSW-C, LMSW)
Education
Required Bachelor's Degree
Working Conditions
Need to drive to perform responsible duties.
Work with computers, typing, reading or writing.
Position Social Worker- CCTLocation Req ID null
