Job Description

Overview:

HarmonyCares is one of the nations largest home-based primary care practices. HarmonyCares is a family of companies all dedicated to providing high-quality, coordinated health care in the home. This includes HarmonyCares, HarmonyCares Medical Group, HarmonyCares Home Health and HarmonyCares Hospice.

Our Mission - Through Compassionate Patient-Centered Care in the Home; We will Provide Exceptional Outcomes across our Continuum of Services

Our Values - Respect, Integrity, Teamwork and Excellence - are leading us to a better tomorrow for patient care.

Why You Should Want to Work with Us

• Quarterly Bonuses - up to $5000 per year!
• Health, Dental, Vision, Disability & Life Insurance, and much more
• 401K Retirement Plan (with company match)
• Tuition, Professional License and Certification Reimbursement
• Paid Time Off, Holidays and Volunteer Time
• Paid Orientation and Training
• Day Time Hours (no holidays/weekends)
• Great Place to Work Certified
• Established in 11 states
• Largest home-based primary care practice in the US for over 28 years, making a huge impact in healthcare today!

Responsibilities:

The Clinical Social Worker works collaboratively with the Care Team to provide care management services and helps address an individuals ability to maintain independence in the home, chronic care management, end of life decisions, cognitive/functional status, frequency acute care utilization, and a patient/caregiver support system. As a Clinical Social Worker you will:

• Manage a caseload of high risk socially complex patients
• Conduct face to face and telephonic psychosocial assessment with the patient and/or the caregiver
• Investigate psychological and social determinant barriers and design appropriate interventions to assist in closing gaps in care and needs
• Coordinate services to ensure the patient/family understands a treatment plan
• Provide outreach to community based services to support the patients ability to age at home
• Develop and implement shared goals of care with the patient and family
• Provide feedback to the home based primary care physician(HBPCP) to ensure he/she is aware of any early patient changes
• Participate in Multidisciplinary Care Planning Rounds
• Conduct additional psychosocial assessments as patient needs change
• Work with Community based agencies to develop relationships and provide appropriate resources to assist in maintaining patient independence
• Other duties/projects as assigned
• Participates in quality improvement activities aimed to improve patient-population outcomes and associated processes.

Qualifications:

Required Knowledge, Skills and Experience

• Masters Degree in Social Work
• Current unrestricted Social Work License or Limited License with preceptor or must be a licensed and boarded CSW or become licensed and boarded within 1-year
• Must maintain a valid drivers license and good driving record
• 3 years of experience in Care Management in community based setting or equivalent
• The ability to use sound clinical judgment and communicate clearly in both written and verbal formats
• Above average computer skills
• Ability to be self-directed and able to communicate effectively with professional staff across many disciplines and programs
• Must have the ability to plan time effectively, balance multiple tasks, work within stringent time frames, resolve problems, identify patient service trends, determine system improvements, and implement change
• Ability to share expertise with others and demonstrates an understanding of the need to foster performance improvement while achieving patient satisfaction and efficiency
• Experience with the homebound population, managed care, ACO, medical home or integrated case management environment is preferred

Preferred Knowledge, Skills and Experience

• Experience working with the chronic, complex and/or behavioral health population

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HarmonyCares