Care Social Worker South Austin

Well Med, part of the Optum family of businesses, is seeking a Care Coach Connect Social Worker to join our team in Austin, TX. Optum is a clinician-led care organization that is changing the way clinicians work and live.

As a member of the Optum Care Delivery team, you'll be an integral part of our vision to make healthcare better for everyone.

At Optum, you'll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. Here, you'll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. We believe you deserve an exceptional career, and will empower you to live your best life at work and erience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country.

Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together.

The Care Coach Connect Social Worker is responsible for the assessment, planning, coordination and oversight of services for identified patients. The position identifies, evaluates, and provides management of services for patients with complex, catastrophic, Social Determinants of Health and/or psychosocial issues to promote quality, effective outcomes throughout the care continuum. The position ensures compliance with state and federal health plan requirements, Medicare guidelines and standards.

The social worker acts as a liaison to coordinate and collaborate care with physicians, family, and other providers while always remaining an advocate for patients, putting them at the center of care delivery. The Social Worker will interact and engage with others as an interdisciplinary team member.

• Performs comprehensive evaluations and documents findings in a concise/comprehensive manner that is compliant with documentation standards for the Center for Medicare and Medicaid Services (CMS)
• Performs patient assessments telephonically, virtually, or in the patient's home as needed
• Understands and plans to assure services provided work within the boundaries of the patient's plan eligibility. Coordinates identified patient's needs utilizing federal, state, and local community resources, as available
• Coordinates with external and internal teams to minimize obstacles and increase in patient and provider satisfaction
• Actively participates in staff and Interdisciplinary Team (IDT) meetings
• Adheres to organizational and departmental policies and procedures
• Maintains a high level of professionalism and adheres to the Well Med Core Values
• Assumes responsibility for personal and professional development
• Ensures licensure, certifications, and annual training are maintained and compliant
• Maintains knowledge of current health plan benefits
• Conducts advanced care discussions with a patients and their families and properly documents their wishes in the electronic medical record
• Exhibits professionalism and is courteous with all patients, physicians and co-workers. Follows Care Coach Connect providers' orders regarding the scope and frequency of services needed based on acuity and patient/family needs
• Maintains a patient case load, daily visits and point of care documentation levels as per standards
• Documents in the electronic health record progress toward established goals as per standards
• Performs other duties as assigned

In 2011, Well Med partnered with Optum to provide care to patients across Texas and Florida. Well Med is a network of doctors, specialists and other medical professionals that specialize in providing care for more than 1 million older adults with over 16,000 doctors' offices. Well Med our focus is simple. We’re innovators in preventative health care, striving to change the face of health care for seniors.

Well Med has more than 22,000+ primary care physicians, hospitalists, specialists, and advanced practice clinicians who excel in caring for 900,000+ older adults. Together, we’re making health care work better for everyone.

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

• Bachelor of Social Work with 3+ years of experience beyond the required years of experience
• Current BLS certification or must obtain certification within 30 days of employment hire date
• 3+ years of social work experience in a health care environment
• Proficient in MS Office Suite to include Word, Excel, Notes, Outlook, and other departmental specific programs/applications
• Proven excellent oral and written communications skills
• Proven solid organizational skills
• Proven ability to prioritize, plan, and handle…