Social Worker; LPC​/LCSW - Community Health Center

Social Worker – Community Health Center

Odyssey House Louisiana, Inc. is seeking a full-time Social Worker for the Community Health Center. The schedule is Monday‑Friday 8:00 am–5:00 pm. The Social Worker will provide comprehensive assessment and diagnosis of behavioral health clients, support primary care providers and Program Managers in implementing disease‑management programs, participate in the development and evaluation of the family and/or client’s plan of care, identify patients who could benefit from disease‑management and case‑management services, educate and engage patients in self‑management, identify social and medical barriers to health outcomes, link patients to appropriate levels of care and supportive services, work collaboratively with a multidisciplinary inter‑agency team, monitor patient ED and hospitalization utilization rates, and use an internet‑based care‑management system to track patient progress and health outcomes.

• Coordinate/facilitate patient care;
• Provide direct care to patients within the scope of practice for which the provider is licensed;
• Provide direct care to clients/patients to support the agency’s department;
• Manage patient care under best practices, UDS recommendations, and as prescribed to maintain accreditation;
• Conduct thorough documentation of visits and medical orders to support billing charges;
• Complete billing components of visit to optimize revenue within dictated time frames;
• Work collaboratively and maintain communication with patient care team (providers, nurses, etc.) to provide effective, timely, and appropriate patient care management;
• Assist patients and providers to adhere to evidence‑based treatment protocols for specific disease states;
• Educate patients and help to engage them in their own care management, provide asthma and diabetes education;
• Monitor patient care by tracking patient charts, counsel patients during physician visits, follow up through telephone calls and home visits as needed, and utilize internet‑based case‑management tracking system;
• Meet directly with patient/family to assess needs and develop an individualized care plan as necessary;
• Ensure/maintain plan consensus from patient/family, physician, and health care team;
• Collaborate with relevant community‑based social services and health care organizations (social workers, home health care, school nurses, hospice providers, etc.) to address patient needs/barriers to improved health outcomes and to secure necessary care and equipment;
• Address/resolve system problems impeding progress; proactively identify and resolve delays and obstacles to expedite care;
• Utilize advanced conflict resolution skills as necessary to ensure timely resolution of issues;
• Collaborate and communicate with multidisciplinary team at all phases of planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, and teaching and ongoing evaluation;
• Identify patients with need for Patient Assistance Program submission to pharmaceutical companies in order to offset the cost to patient (including assisting patient in filling out application, identifying needed documents to support income, ensuring provider licenses are submitted, application is signed by provider, managing the course of application, notifying patient of arrival of medicine, and logging of applicants);
• Perform utilization management and quality screening for assigned patients;
• Identify at‑risk populations using approved screening tool(s) and follow established care and reporting protocols;
• Monitor medical resource use on an ongoing basis and take action to achieve continuous improvement;
• Refer cases and issues to PCP and follow up as indicated; follow up on referrals from PCP as appropriate;
• Actively participate in clinical performance improvement activities;
• Participate in development, implementation, evaluation and revision of disease‑management tools as a member of the clinical change team;
• Attend local meetings as necessary;
• Participate in training as necessary to successfully complete job responsibilities, including training in disease‑management protocols, care‑management…