The Licensed Clinical Social Worker will follow a collaborative process of identifying, planning, advocating for, coordinating, monitoring, evaluating resources, supports, and services to meet the psychosocial and community needs of the assigned population. The Licensed Clinical Social Worker will be an integral part of the multidisciplinary team known as the ACTIVE Diabetes Program. This position includes collaborating with physicians, clinical pharmacists, and registered dietitians to manage patient with diabetes who are not at goal for their A1c, despite traditional management from their primary care physician and/or endocrinologist. Eligible patient populations include HMO, ACO, PPO, and Medicare. The expectations regarding patient care and follow up will be guided by protocols developed by the ACTIVE Diabetes Program based on current evidence-based medicine
Essential Functions and Responsibilities of the Job
Treats patients and/or families in a caring, respectful manner while respecting confidentiality and privacy
Cultivates a therapeutic relationship with each patient and/or family member
Attends/coordinates appropriate Patient Care Conferences and/or meetings as necessary
Acts in accordance with the mission, values, ethical principles and standards of the social worker role responsibility
Practices within scope of practice
Computer literacy with ability to work within several internal and external on line and Web based systems, reports and analytics
Maintains and complies with all Memorial Health Systems policy and procedures.
Interact in a positive and constructive manner
Essential Job Outcomes
Engages the patients and/or families in the care management process, tailoring plans of care to the patient’s needs, preferences, and goals.
Advocates for empowering patients to maintain a level of control over their treatment and for self-determination
Engages in Behavioral Health therapeutic techniques and interventions when identified and under the scope of his/her LCSW license.
Collaborates with other members of the interdisciplinary team regarding the care management process
Assesses the patients psychosocial in a holistic manner
Has knowledge and utilizes a variety of community resources to meet the psychosocial needs of the patients
Collaborates with team to create plans of care to avoid overutilization due to lack of psychosocial resources
Collaborate with team to prevent unnecessary emergency room visits and/or hospitalizations
Initiate and assist with advanced care planning discussion when appropriate
Documents in a timely, complete, and thorough manner