Bilingual Medical Social Worker MSW

Suvida Healthcare LLC; Austin (TX); On-site; USD 70,000 - 100,000; Full time

Job summary

Suvida Healthcare LLC is seeking a Senior Guia to provide clinical social work and complex case management for Medicare-eligible seniors. You will assess plans of care, coordinate services, and collaborate with an interdisciplinary team to address social, financial, and care needs across the continuum.

Strong knowledge of resources and community programs is essential. The role requires mastery of clinical social work practice, advocacy for autonomy, and proficient documentation across home,

Qualifications

• Therapeutic communication and negotiation skills with patients and families.
• Experience coordinating care within a multidisciplinary team.
• Knowledge of ICD-10 and Z codes.

Responsibilities

• Provide comprehensive care coordination to a caseload of patients.
• Collaborate with patients, families, and caregivers to plan and execute interventions.
• Develop treatment plans and monitor progress across care transitions.
• Document interventions in the medical record accurately and timely.
• Advocate for patient resources, including government and community programs.

Skills

Therapeutic communication

Interdisciplinary teamwork

ICD-10 knowledge

EMR proficiency

Education

MSW preferred

LMSW or equivalent

Job description

About this position

Who We Are

At Suvida Healthcare, we are not just caregivers; we're compassionate advocates dedicated to enriching the lives of our cherished seniors. As a Team Member with us, you will embark on a fulfilling journey where your skills and empathy converge to make a meaningful impact on the well-being of an underserved community and their families. Our multi-disciplinary primary care program is built to address the physical, behavioral, social, and cultural needs of Medicare-eligible Hispanic seniors.

Celebrate diversity and inclusivity in a workplace that attracts, engages, values, rewards, and recognizes the unique needs and backgrounds of both, our patients and our team. We believe that a rich tapestry of experiences, shared interests, and perspectives enhances the care we provide, making us a stronger, service-centered, and more compassionate healthcare family and Employer of Choice! Will you join us Suvidanos, to help achieve our Higher Purpose?

What Makes Us Unique

We are an empowered primary care, clinical operations, and support team creating health equity through an exceptional clinical and consumer experience that improves the quality of life for the people, families, and neighborhoods we serve. We tailor our primary care program to the culture, language, social, and overall well-being of the seniors we serve.

How We Work

Our Culture & Core Beliefs

Earn TrustBuilding RelationshipsCreating JoyDoing RightImproving Every DayMoving Forward

Who We Are

At Suvida Healthcare, we are not just caregivers; we're compassionate advocates dedicated to enriching the lives of our cherished seniors. As a Team Member with us, you will embark on a fulfilling journey where your skills and empathy converge to make a meaningful impact on the well-being of an underserved community and their families. Our multi-disciplinary primary care program is built to address the physical, behavioral, social, and cultural needs of Medicare-eligible Hispanic seniors.

Celebrate diversity and inclusivity in a workplace that attracts, engages, values, rewards, and recognizes the unique needs and backgrounds of both, our patients and our team. We believe that a rich tapestry of experiences, shared interests, and perspectives enhances the care we provide, making us a stronger, service-centered, and more compassionate healthcare family and Employer of Choice! Will you join us Suvidanos, to help achieve our Higher Purpose?

What Makes Us Unique

We are an empowered primary care, clinical operations, and support team creating health equity through an exceptional clinical and consumer experience that improves the quality of life for the people, families, and neighborhoods we serve. We tailor our primary care program to the culture, language, social, and overall well-being of the seniors we serve.

How We Work

Our Culture & Core Beliefs

Earn TrustBuilding RelationshipsCreating JoyDoing RightImproving Every DayMoving Forward

What You’ll Do

Position Summary

TheSenior Guiasystematically intervenes to provide clinical social work and complex case management to patients and their families who have complex psychosocial needs, require assistance with eligibility determination for social programs and funding sources, and qualify for community assistance from a variety of special funds and agencies. This position assesses the patient’s plan of care and develops, implements, monitors, and documents the utilization of resources internally and externally and progress of the patient through the continuum of care. The intensity of care coordination provided is situational and appropriate based on patient need and payer requirements. This role participates in an interdisciplinary team (including Physicians, Case Managers, Staff Nurses and other members of the care team) to provide services for high risk patients and ensure that psychosocial needs are attended to and treated as required across the continuum of care.

Responsibilities

Providescomprehensivecare coordination to an assigned patient caseloadWorks collaboratively with patients, family, caregivers, healthcare providers, and external partners to meet complex medical patient needsAs part of a multidisciplinary team, develops and carries out a treatment planby the use ofa clinical social work diagnosis,assessmentand treatment interventionsIntervenes with patients and familiesregardingemotional, social, and financial consequences of illness and/or disabilityAssesses,mobilizesand provides follow up on family/community resources to meet social care needsProvides intervention in cases involving elder abuse/neglect, domestic violence, guardianship (temporary/permanent), mental health placement, and sexual assaultInitiates andassistspatients with advance directivesCollaborates with patients/caregivers to include supportive care, end-of-life decisions, community resources/programs, goal setting, and long‑term planning needsFormulates care plan of intervention acceptable to the patient, family, and health care teamReceives referrals for complex patient problem resolution from case managers or clinical care team membersWorks in collaboration with the clinical and case management team on transitions of care planning and referrals topost acuteprovidersPromotes a collaborative process and communication between all health care team members, internal multidisciplinary teams, inclusive patients/clients, families, and significant others to ensure the process of integrated care services are targeted,appropriate, and beneficialAdvocatesutilizingknowledge of applicable laws, regulations, government, and insurance benefits as well as practice guidelines and standards of practiceAdvocates for patient and family empowerment and independence to make autonomous health care decisions and access needed services within the health care systemProvidesfollow upandassistanceto patients in a variety of settings: in-home, in-clinic, and in the ancillary setting- hospitals, group homes, skilled nursing facilities, etc.Documents all interventions in the patient medical record bothtimelyand accurately including all elements of clinic visits, in home, telephonic engagement, or textingMaintains knowledge of Medicare, Medicaid, and other program benefits toassistpatients with resource allocation and choicesHas freedom todeterminehow to bestaccomplishfunctions within established proceduresProvides consultation tolow riskguiason patients with significant or intensive community resources needsParticipates in the development and maintenance of case management metricsProvides professional education to staff and communityFacilitatesSuvidasponsored support groupsOther duties as assigned by Guia Manager

What You’ll Bring

Knowledge, Skills, and Abilities

Acute inpatient hospital social work experience preferredExperience managing the needs of Senior/Geriatric populationsExperience assessing and addressing the social determinant of healthWorking knowledge of ICD-10 and Z codesProficiencywith EMRs, computers, mobile devices, medical devices, and Microsoft Office SuiteExcellent therapeutic communication and negotiation skills in interactions with patients, families, physicians, and health care team colleaguesExposure and/or experience in pre‑acute and post‑acute careExpertiseconnecting patients and ensuring closed loop referral with community resources and governmental agencies that address complex social needsAbility to work independently, as well as, to develop collaborative relations with physicians, families, patients, interdisciplinary team members, and community agencies

Education, Experience, Licensure, or Certification Requirements

Graduate of an accredited Master of Social Work program (MSW)preferredRequires a Licensed Master Social Worker (LMSW)or equivalent3-5 years of experienceANDCHW certification plus 6- 8yearssocial workexperience.Must have knowledge of government/community resources as well as Medicare, Medicaid, long-term care, or any other applicable resources/servicesMust have knowledge for transacting LIS, PAP, and SNAP applications and other foundation applicationsMustdemonstratecritical thinking skills, problem‑solving abilities, effective communication skills, relationship building skills, and time management skill

Suvida Healthcare provides equal employment opportunities to all Team Members and applicants for employment and prohibits discrimination and harassment of any typewithregard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.