Provides direct client services and supervision of daily operations and staff that provides services for community based populations. These populations include those at risk who need intensive support to manage social determinants of health that negatively impact their social, emotional, and physical well-being. Direct client services are provided through broad knowledge and experience of social work theories and methodologies, clinical care, systems management, and community/government networks. Coaches and guides team members to align client service needs with appropriate resources to optimize health. Monitors and mentors staff to enhance care coordination and clinical skills. Provides support to the Carelink CareNow population health leadership, as well as assistance with program development, service delivery improvement, special projects, and staff engagement.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
Performs a comprehensive in person assessment and ‘home’ evaluation, detailing the psychosocial and environmental factors and their effects upon the client's health and well-being
Partners with client in crisis to create an individualized care plan which promotes client's eligibility for community, regional and national services to support their health goals.
Collaborates effectively with multi-disciplinary team in developing care plans consistent with evidence-based care guidelines that sustain longitudinal social, emotion and physical health improvement and stability. Facilitates team collaboration efforts.
Partners with individuals and families to create a holistic treatment plan which addresses the behavioral health and chronic medical conditions that serve as barriers to health;
Adapts behaviors and goals, in a culturally competent, trauma informed manner, based upon an individual's background, social situation, experience, and wishes.
Effectively prioritizes clients whose situations require immediate intervention to prevent negative health outcomes
Collaborates with other Carelink CareNow colleagues to ensure smooth transitions of care across the continuum.
Advocates for clients when needed, empowering them to achieve their goals, including individual and/or class inequities, inadequate or non-existent hospital and/or community resources (i.e. insurance, housing, benefit applications, verification documents, etc.)
Educates clients regarding their social, medical and emotional needs and how to navigate resources to meet these needs, including the appeal process.
Engages eligible clients in the program according to established protocols and enrollment procedures
Serves as a subject matter expert for other Carelink CareNow, Christiana Care Health System or community staff when addressing complex health, social and behavioral health needs; Leads multi-disciplinary case review to optimize outcomes.
Effectively and efficiently prioritizes work; Documents in a timely, accurate and concise manner per Carelink CareNow policy. This includes but is not limited to: operations, regulatory needs, research initiatives and quality assurance requirements.
Demonstrates and supports strong and respectful communication skills with patients, community partners and colleagues, appropriately following lines of authority via the CCHS organizational chart.
Supports outreach through active participation in community meetings, client team meetings, and Carelink CareNow staff/team meetings.
Performs assigned work safely, adhering to established departmental safety rules and practices
Reports immediately to administration any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients and/or visitors
Assumes responsibility for professional growth and shares knowledge with co-workers and health care team members.
Supervises undergraduate or graduate students enrolled in an accredited school of social work as required
Provides information on social service programs and state/ federal regulations specific to the population that is served.
Supports Carelink CareNow activities for members of the team including identification and resolution of team issues, responsibility for the reassignment and coordination of services, facilitates the distribution and completion of daily work.
Assumes PTO, disability time, and FMLA oversight to insure that staffing is optimal to meet service needs for all staff located at their site.
Provides direct supervision of staff to include preceptoring, mentoring, coaching and evaluation.
Coordinates and initiates training/orientation programs for staff; coordinates ongoing educational presentations – in cooperation with other members of Carelink CareNow.
Maintains employee files as needed in cooperation with the department director.
Oversees client and staff satisfaction initiatives; to include review of data management tools, analysis of service needs, and dissemination of all information related to the process to staff members.
Communicates with internal/external customers (i.e., social work agencies, government agencies, etc.); and acts as a representative of Carelink CareNow Community to communicate issues as needed.
Coordinates/schedules meetings to support the needs of staff members and improvement of service delivery.
Assists in preparation of budget items in cooperation/coordination with the departmental director.
Makes recommendations for budgetary needs within scope of assignment.
Participates in the development and maintenance of departmental policies and procedures for Carelink CareNow Community.
Participates in quality assurance and performance improvement activities specific to Carelink CareNow Community functions, initiatives and regulatory guidelines.
Interacts with both internal and external customers of the Carelink CareNow Community; to include Information Services, Fiscal Services, ancillary departments, Third Party Payers, community social service agencies, health care facilities, and regulatory bodies to maintain/update policies and procedures.
Performs work safely, adhering to established departmental safety rules and practices;
monitors/reports any unsafe activities, conditions, hazards or safety violations that may
cause harm to self &/or others.
Performs other related duties as required
EDUCATION AND EXPERIENCE REQUIREMENTS: Master's degree in Social Work (MSW) from an accredited graduate school of Social Work required. Minimum of 7 years social work experience in health care environment; with at least 2 years in a supervisory capacity, Behavioral health and community work preferred Direct experience in transition planning, insurance authorization and arranging community services for complex populations
Internal Number: 46464BR
About Christiana Care Health System
Christiana Care Health System is headquartered in Wilmington, Delaware and is one of the country's largest health care providers, ranking 21st in the nation for hospital admissions. Christiana Care is proudly a Nurse Magnet recognized institution. Christiana Care Health System is also one of the largest health care providers in the mid-Atlantic region, serving all of Delaware and portions of seven counties bordering the state in Pennsylvania, Maryland and New Jersey. A not-for-profit, non-sectarian health system, Christiana Care includes two hospitals with more than 1,100 patient beds, and is a major teaching hospital with two campuses. Christiana Care is continually recognized for excellence on a regional and national level. Our role in the community is expressed in the Christiana Care Way: "We serve our neighbors as respectful, expert, caring partners in their health. We do this by creating innovative, effective, affordable systems of care that our neighbors value."Christiana Care is a great place to work because we value diversity and recognize it to be a core part of our success. Because of the diversity of our employees, affiliated health professionals and volunteers, we are... positioned to meet the unique needs of our patients and community. We acknowledge and celebrate the uniqueness and talent of each employee. Because of our talented workforce we are able to provide a quality healthcare experience to our patients and community. We strive to create an inclusive environment in which individual diversity can be leveraged and thrive. Christiana Care Health System is an equal opportunity employer, firmly committed to prohibiting discrimination, whose staff is reflective of its community and considers qualified applicants for open positions without regard to race, color, sex, religion, national origin, sexual orientation, genetic information, gender identity or expression, age, veteran status, disability, pregnancy, citizenship status, or any other characteristic protected under applicable federal, state, or local law.