Social Work Care Advisor- IHCI

Overview

Community Health Network was created by our neighbors, for our neighbors. Over 60 years later, “community” is still the heart of our organization. It means providing our neighbors with the best care possible, backed by state‑of‑the‑art technology. It means getting involved in the communities we serve through volunteer opportunities and benefit initiatives. It means ensuring our dedicated caregivers can learn and grow to stay at the top of their fields and to better serve our patients.

And above all, it means exceptional care, simply delivered — and we couldn’t do it without you.

The Innovative Healthcare Collaborative of Indiana (IHCI) is a joint venture between Community Health Network and Deaconess Health System. Its goal is to support our sponsors and partners in their strategic evolution to positively impact and improve the healthcare delivery system. This position is primarily REMOTE but there is potential for some physician office‑based duties. Patient coordination will be telephonic. The role will provide both direct social work care management to various high‑risk patient populations, as well as psychosocial, environmental and financial consultation to other members of the care team.

You will serve as a critical member of the integrated care team.

• Provide direct social work care management to high‑risk patient populations.
• Render psychosocial, environmental and financial consultation to members of the care team.
• Coordinate patient case management telephonically and support physician office‑based duties as needed.
• Engage patients and caregivers in developing care plans focused on behavioral, clinical, social and environmental concerns.
• Develop a Plan of Care based on assessment to link patients to appropriate demographic resources.
• Ensure required data is accurate and consistently captured in the EMR and act as liaison to escalated clinical care issues when indicated.
• Communicate with nursing staff in situations that require nursing judgment.
• Develop and maintain a comprehensive inventory of local community resources, improving accessibility for patients and providers.
• Link patients to community resources such as housing support, medication assistance, finance and insurance assistance, and other needed resources as appropriate.
• Evaluate patient needs through psychosocial, environmental, and financial assessment; make referrals, follow‑up weekly, and provide education and self‑management support based on the patient’s preferences and financial resources.
• Utilize a variety of outreach strategies to engage various patient populations and advocate on behalf of patients.

• LSW or LCSW in the State of Indiana required.
• Bachelor’s degree in Social Work required.
• Master’s degree in Social Work preferred.
• 2 years experience providing social work services within a variety of population health and/or value‑based care program settings preferred.
• 2 years knowledge of care resources for targeted populations; comfortable with technology including Microsoft suite and prior experience using electronic health records including data capture, data mining and reporting required.
• 3 years medical or community Social Work experience providing patient‑centered outreach, behavioral health services, needs assessment and support required.

At Community Health Network, we build teams that deliver exceptional care through empathy, communication and collaboration. We consider ALL as an integral part of the exceptional patient experience. We proudly define ourselves as having Caregivers, not employees. Join our Community and make a difference in yours.