Care Advisor, Social Worker
Evolent Health is seeking a Social Worker to be founding members of the Population Health team with a special focus on members who are medically frail. Our goal is partnering with the nation’s leading health systems in their strategic evolution to positively impact and improve the healthcare delivery system. As a member of a team of nurses, social workers, registered dieticians, physicians, pharmacists, and program coordinators, you will have the opportunity to make a profound impact on the lives of people living with multiple chronic illnesses. You will connect with your patients primarily on the phone, but could be in person and through email, in the hospital, and in the physician’s office - essentially however and wherever the patient needs your assistance to improve their health, better understand their illness and coordinate their care.
What You’ll Be Doing:
This position is responsible for care management activities for members who are medically frail including telephonic outreach and engagement, assessment, planning, facilitation, evaluation and advocacy for options and services to meet a patient’s comprehensive needs through communication and available resources to promote quality, cost-effective outcomes.
- Provide Care Management activities to support the Medically Frail program.
- Conduct outbound calls to members (and others on members’ behalf) following scripted protocols. Conducts all calls in a courteous and customer friendly manner.
- Meet productivity and performance expectations as identified by the Manager and/or designee. Verify member eligibility according to the appropriate eligibility system.
- Conduct comprehensive assessments that identify medical, behavioral, clinical, social and environmental concerns and needs of patients, and identify gaps in care and barriers to attaining improved health.
- Based on this assessment, and in conjunction with the patient, the patient’s physician and other members of the population health team, create a care plan that will address the identified needs, remove the barriers and improve the health of the patient.
- Coordinate care by serving as the contact point, advocate, and resource for the patient, their family and their physician, building effective relationships through trust, respect, and communication.
- Work with member to increase member's adherence to program guidelines, including coordinating with primary care physicians.
- Continually assess the patient’s knowledge of his or her clinical and social conditions and provide education and self-management support based on the patient’s unique learning style.
- Provide backup coverage for team members when out of the office on leave.
- Help to maintain a comprehensive inventory of local community and government resources for patients and their families and facilitate the patient’s access to these resources.
- Serve as a contact for other entities serving assigned populations.
- Report issues encountered by members in assigned populations; suggest solutions to recurring problems, work with other teams as needed.
- Conduct and document the care management processes, focusing on the whole health needs of all assigned members, and including assistance in resolving issues encountered by members related to accessing needed care and treatment.
- Act as a liaison between member, provider and health plan to assure healthcare services are provided in the most appropriate and cost-effective manner.
- Facilitate access to entitlement programs and/or community resources.
- Follow up regularly with members, guardians, and/or caregivers to ensure members’ care needs continue to be met appropriately.
- When assigned by Manager, participate in meetings with external entities such as state and/or community partners, caregivers, or members.
- Perform administrative duties tied to care management activities
- Prepare and assign letters and other educational material to be sent to patients.
- Document information required for outcome measurements.
- Attend required annual trainings.
- Participate in Collaborative Care Rounds quarterly.
- Complete/maintain reports as requested by Manager.
- Comply with Passport and HIPAA confidentiality standards to protect the confidentiality of member information.
- Identify and correct problems with members who are medically frail. Demonstrate a broad knowledge of Passport Health Plan, Medicaid benefits, services, and requirements.
- Live the Evolent Values
- Communicate effectively. Listen attentively to others.
- Seek creative solutions that meet the needs for all parties involved.
- Cooperate with others to achieve departmental goals, interdepartmental relations, and public relations.
- Adapt to change in a way that promotes success with minimal disruption of departmental activities.
- Display willingness to work as part of a team. Maintain cooperative relationships with all team members.
- Demonstrate knowledge of NCQA, HEDIS, and program goals.
- Perform other duties and projects as assigned.
- Work from the office or home; ability to work from home dependent on completing job role competencies and meeting job role expectations.
- Work a flexible work schedule – may need to work evenings/occasional weekends to provide patient access and/or follow up.
- Fully licensed behavioral health professional (LCSW, LMFT, LPCC, LPAT, etc.) who holds a current independent license issued by a Kentucky state licensing board
- Master’s degree in a behavioral health field – Social Work, Marriage and Family Therapy, Educational Counseling, etc.
Evolent Health is an Equal Opportunity/Affirmative Action Employer