Master of Social Work Care Coordinator

Job Description

Job Description

Arizona Community Physicians

Master of Social Work Care Coordinator – Abacus Health ACO

Job Description

The Master of Social work (MSW) Care Coordinator works under the direction of the Accountable Care Organization (ACO) Medical Director and RN Care Coordination Manager in Care Management and Population Health. A prime area of focus will be case management of higher risk pediatric patients. Other areas of focus may include transitional care management, population health management, quality improvement, staff education, engagement and patient support through various Care Management Programs.

As a team member with Abacus Health, we serve through our mission and purpose of the Triple Aim + 2:

1. Improving the patient’s experience of care (quality and satisfaction)

2. Improving the health of populations

3. Reducing the per capita cost of health care

+2 Includes improving physician and employee satisfaction and Abacus income

Primary Responsibilities

Clinical:

• Work with the ACO Medical Director to improve clinical outcomes and help reduce total medical costs.
• Assist in ACO-directed quality improvement efforts to foster innovation as ACO continues to evolve new patient care programs.

Care Coordination:

• Interact daily with clinical offices affiliated with Abacus Health ACO to provide care coordination for patients needing short-term care coordination.

Case Management:

• Support pediatric high-risk patients and families with the purpose of helping them be more effective at managing their own care.
• Empower families, caregivers, and patients to understand their medical conditions and medications, navigate the healthcare system and access and utilize resources appropriately.
• Provide education and emotional support to families and patients and develop trusting relationships with them.
• Create a patient centered plan with each patient and consistently document all interactions with each patient.
• Communicate significant clinical information regarding patients to other members of the healthcare team, specifically to the patient’s Primary Care Provider (PCP).

Short-term Care Management:

• One-time or limited outreach assistance with Care Coordination.
• Act as a liaison between community resources helpful to patients (e.g., volunteer agencies, assistance programs) and educate assigned ACP staff about community resources that can help them in office management of high-risk patients.
• Use advocacy, communication and resource management, while promoting quality and cost-effective interventions and outcomes.
• Facilitate the achievement of patient wellness and autonomy through advocacy, assessment, planning, communication, education, resource management, and service facilitation.
• Maintain appropriate documentation to track quality improvement and cost reduction activity

Customer Service:

• Promotes excellence in patient relations and customer service, emphasizing compassion, responsiveness, respect and courtesy.
• Uses active listening skills, gathering information to enhance patient care and improve patient health outcomes.

Teamwork:

• Works harmoniously with others, demonstrating a commitment to achieving common goals.
• Communicates in a manner that promotes trust and mutual respect.
• Maintains a professional demeanor in dealing with conflict and difficult issues.
• Adapts to changes in job duties and workplace with a positive and cooperative demeanor.

Qualifications

• Education: Completion of an accredited MSW program.
• Current Arizona LMSW license.
• Excellent written and verbal communication skills.
• Proficient with MS Word, Excel and Outlook.
• Computer proficiency and ability to quickly learn new applications.
• Communication and people-relationship skills to work with a diverse range of people.
• Skills in organization, prioritization, and multi-tasking.
• Professional demeanor and recognition of privacy considerations for patients and families.
• Must be able to act calmly and effectively in a stressful situation.
• Must be able to establish and maintain effective working relationships with medical staff and peers.
• Preferred Experience/Qualifications: Population Health Management, Case Management in

medical setting, Pediatric Experience is desirable.