The Coordinator-LCSW works under the supervision of the Manager of Transitional Services and is responsible for the administrative and operational activities of the clinical BH programs of Population Health. The Coordinator regularly performs the job duties of the LCSW and is accountable for assuring quality outcomes. The Coordinator has the authority to enforce the Standards of Behavior and works to ensure the mission, vision and values for the organization are upheld on a daily basis. Collaborates with the individual, family, physician, interdisciplinary team and plan to organize, coordinate, and monitor the provision of quality and efficacious healthcare services and resources to promote optimal patient outcomes and managing total cost of care. Ensures medically necessary, behavioral services are provided in a cost-effective manner and identifies outliers in utilization trends. Manages members with mental illness(es) who have high rates of behavioral health utilization and/or psychosocial vulnerability. Assess members to recommend activities and behavioral routines to meet the social and medical needs of members and their families. Provides support and/or intervention and assists members in understanding the implications and complexities of their current medical situation and/or overall personal care. Assists the Population Health team with specialized support to patients and families in various behavioral health conditions, new diagnosis of catastrophic disease, end of life counseling and advanced care planning, placement education, and complex family dynamics.
1.Conducts comprehensive psychosocial assessments and counseling with high risk populations to enhance the plan of care, provide and/or coordinate appropriate interventions, and recommendations for follow-up care and services. Coordinates transitions with clinical and non-clinical care team members to ensure a seamless transition and support of services.
2.Facilitates and coordinates behavioral health resources as individual member needs are identified while serving as a resource to patients and families in dealing with and managing conflict that can occur during an acute medical crisis.
3.Uses appropriate screening criteria knowledge and clinical judgment to assess, monitor, plan, and implement member needs to ensure access to medically necessary, high quality behavioral healthcare in a cost-effective setting following UM clinical guidelines. Refers cases to peer reviewers as needed. Reviews population trends and utilization of services to ensure adequate support/level of care and cost effectiveness.
4.Practices within the strength-based perspective to identify patient and family strengths and assist patients in building on these strengths to empower them to work toward positive change.
5.Assumes level of “expert” knowledge of community resources and facilitates connecting patient/families with needed services. Facilitates referrals for patients with social determinant of health barriers to support their health care needs, connecting them with resources such as Department of Social Services for Medicaid, prescription support programs, and the like.
6.Provides and facilitates educational and/or process groups with specific populations in areas of the medical care setting as needed (i.e., newly diagnosed medical illness, coping with grief and loss, lifestyle change)
7.Assists patients and their families in addressing issues and concerns relating to domestic violence or abusive relationships including facilitating receipt of services to empower safety. Reports suspected cases of child & adult abuse/neglect/exploitation. Serves as liaison between providers, patients/patient's social support system and Department of Social Services during evaluation/investigation
8.Assists the medical team in assessment of patients with emotional and behavioral disorders, substance abuse and dual diagnosis patients, provides supportive counseling to these patients, their families and significant others and assists them in making follow-up arrangements or transfers to more specialized treatment facilities
9.Facilitates/Assists patients/families in open discussions regarding advanced care planning to aide in their decision making of end of life care.
10.Utilize complex decision making and problem solving skills that facilitate developmentally appropriate patient outcomes.
11.Acts as an advocate for the patient to ensure their needs are met and their rights protected.
12.Participates in outcomes measurement to enhance and improve the quality of services provided to patients and families.
13.Facilitates completion of Level II PASARRs for patients seeking SNF placement per State guidelines.
14.Participates in performance improvement activities based on the patient population by identifying barriers to care, systems and process issues, and contributing to data collection and analysis for improvement plans.
15.Identifies areas for improvement, develops and implements new programs in conjunction with leadership.
16.Coordinates with treatment team members to proactively address concerns related to patients and timeliness of discharges.
17.Facilitates the orientation and education of staff. Tracks adherence of all mandatory education and assists with staff development
18.Addresses disciplinary issues using the disciplinary process following discussion with the manager.
19.Coordinates daily assignments to assure adequate coverage and assists in the development of staffing schedules.
20.Assists with performance appraisals as directed by the management team.
21.Demonstrates standards of performance (ownership, teamwork, communication, compassion) that support patient satisfaction and principles of services excellence.
22.Interacts in a professional manner and maintains the ethical standards of NASW Code of Ethics.
23.Maintains and sustains LCSW licensure consistently through the North Carolina Social Work Licensing Board (NCSWLB).
24.Organizes and performs work effectively and efficiently.