Community Based Social Work Care Coordinator

LOCATION: Stroger Hospital of Cook County

SHIFT: 8:00AM to 4:00PM

Job Summary SEIU 73

The Community Based Social Work Care Coordinator (CBSWCC) supports the provision of care coordination in a manner that recognizes the Enrollee and the medical home care teams as essential partners in the Enrollee’s care. These services are offered at the Enrollee’s home, physician office, and/or other health care facilities. If it is determined the Enrollees care is medically complex the CBSWCC collaborates with a nurse in the provision care coordination. Completes assessments of complex health care needs and/or the presence of social determinants that impact the provision of care. Collaborates with Enrollee and medical home care team to develop and implement a care plan that mitigates barriers and links Enrollees of any risk levels to appropriate resources. The CBSWCC works across sites of care and with multiple disciplines to achieve the desired outcomes for the Enrollees.

Typical Duties

• Conducts outreach to Case Management Department at hospital when Enrollees are admitted.
• Interfaces with Medical Home team and Enrollee at prescribed or agreed upon intervals.
• Conducts face to face visits on members with high or moderate risk stratifications on a quarterly basis.
• Collaborates with medical home assignments to identify resources and process for effective communication.
• Conducts monthly outreach for high risk patients who are stable, more often for patients undergoing a transition or a change in treatment. Updates medical home team on status.
• Provides relevant education, counseling and support to assist member with the achievement of goals.
• Performs other duties as assigned.
• Collaborates with Nurse Care Coordinators on patients with multiple co-morbidities, frequent hospitalizations or inappropriate Emergency Department (ED) visits.
• Completes all required trainings, workshops, etc. within the required timeframe.
• Tracks patient progress regarding goal achievement on the care plan.
• Meets established case deadlines.
• Completes screenings, assessments and care plan in accordance with contractual requirements and Care Coordination policy and procedure.
• Updates documents based on Enrollee progress, changes in priorities, changes in health status or new information.
• Integrates information from claims review, notes, screenings, assessments and Medical Home teams in care plan.
• Supports care coordination referrals from multiple sources including Enrollee request, plan referrals, medical home referrals, grievances, data reports or changes in risk score.
• Convenes the Interdisciplinary Care Teams, presents own patients, and provides guidance on others not directly managed.
• Uses all available information sources to support care coordination activities-this may include portals, electronic medical records, claims data, plan information, utilization management information, and Milliman Care Guidelines (MCG).
• Travels to the home of the Enrollees or their sites of care.

• Licensed in the State of Illinois as a Licensed Social Worker, Licensed Clinical Social Worker (LCSW), License Professional Counselor or Licensed Clinical Professional Counselor (LCPC) is required (must provide proof at time of interview)
• Three (3) years of health care work experience is required
• Prior care management work experience in a social service agency, physician group, hospital or Emergency Department setting is required
• Valid Driver’s license and mandatory vehicle insurance or other means of transportation is required (must provide proof at time of interview)

• Bilingual English/Spanish is preferred

Knowledge, Skills, Abilities and Other Characteristics

• Ability to probe to get to underlying behaviors or Enrollee assumptions that are driving care coordination results
• Knowledge of Microsoft Office products
• Collaborates effectively with team members
• Ability to work independently
• Solution-oriented skills
• Ability to effectively prioritizes tasks
• Ability to work at a fast-paced
• Ability to communicate non-judgmental attitude
• Effectively communicates care coordination benefits to Enrollees, Medical Home Teams and hospital based staff

Benefits Package

For further information on our excellent benefits package, please click on the following link: http://www.cookcountyrisk.com/

VETERAN PREFERENCE

PLEASE READ

When applying for employment with the Cook County Health & Hospitals System, preference is given to honorably discharged Veterans who have served in the Armed Forces of the United States for not less than 6 months of continuous service

To take advantage of this preference a Veteran must :

OR

A copy of a valid State ID Card or Driver’s License which identifies the holder of the ID as a Veteran may also be attached to the application at time of filing.

If items are not attached, you will not be eligible for Veteran Preference

VETERANS MUST PROVIDE ORIGINAL APPLICABLE DISCHARGE PAPERS OR APPLICABLE STATE ID CARD OR DRIVER’S LICENSE AT TIME OF INTERVIEW.

MUST MEET ALL REQUIRED QUALIFICATIONS AT TIME OF APPLICATION FILING.

Degrees awarded outside of the United States with the exception of those awarded in one of the United States' territories and Canada must be credentialed by an approved U.S. credential evaluation service belonging to the National Association of Credential Evaluation Services (NACES) or the Association of International Credential Evaluators (AICE). Original credentialing documents must be presented at time of interview.

COOK COUNTY HEALTH & HOSPITALS SYSTEM IS AN EQUAL OPPORTUNITY EMPLOYER