Bilingual Medical Social Worker MSW

Suvida Healthcare; Austin (TX); On-site; USD 60,000 - 90,000; Full time

Job summary

Suvida Healthcare is seeking a Senior Guia to deliver clinical social work and complex case management for Medicare-eligible Hispanic seniors. You will assess care plans, coordinate resources, and collaborate with a multidisciplinary team to support high-risk patients and families across home, clinic, and community settings.

The role emphasizes social determinants of health, access to government programs, and advocacy to empower patients and carers within the care continuum.

Qualifications

• MSW preferred.
• LMSW or equivalent with CHW certification/experience required.
• Experience with government/community resources and Medicare/Medicaid.
• Strong communication and time management skills.

Responsibilities

• Provide comprehensive care coordination to a caseload of patients.
• Collaborate with patients, families, caregivers, and providers to meet complex needs.
• Develop and carry out treatment plans using clinical social work methods.
• Address emotional, social, and financial consequences of illness.
• Access community resources to meet social care needs.

Skills

Geriatric care

Social determinants of health

ICD-10 & Z codes

EMR proficiency

Therapeutic communication

Pre- & post-acute care

Community resources coordination

Independence & collaboration

Education

MSW preferred

LMSW or equivalent + CHW cert

Tools

Microsoft Office

Job description

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 Trust
• Building Relationships
• Creating Joy
• Doing Right
• Improving Every Day
• Moving Forward

What You’ll Do

Position Summary

The Senior Guia systematically 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

• Provides comprehensive care coordination to an assigned patient caseload
• Works collaboratively with patients, family, caregivers, healthcare providers, and external partners to meet complex medical patient needs
• As part of a multidisciplinary team, develops and carries out a treatment plan by the use of a clinical social work diagnosis, assessment and treatment interventions
• Intervenes with patients and families regarding emotional, social, and financial consequences of illness and/or disability
• Assesses, mobilizes and provides follow up on family/community resources to meet social care needs
• Provides intervention in cases involving elder abuse/neglect, domestic violence, guardianship (temporary/permanent), mental health placement, and sexual assault
• Initiates and assists patients with advance directives
• Collaborates with patients/caregivers to include supportive care, end-of-life decisions, community resources/programs, goal setting, and long-term planning needs
• Formulates care plan of intervention acceptable to the patient, family, and health care team
• Receives referrals for complex patient problem resolution from case managers or clinical care team members
• Works in collaboration with the clinical and case management team on transitions of care planning and referrals to post acute providers
• Promotes 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 beneficial
• Advocates utilizing knowledge of applicable laws, regulations, government, and insurance benefits as well as practice guidelines and standards of practice
• Advocates for patient and family empowerment and independence to make autonomous health care decisions and access needed services within the health care system
• Provides follow up and assistance to 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 both timely and accurately including all elements of clinic visits, in home, telephonic engagement, or texting
• Maintains knowledge of Medicare, Medicaid, and other program benefits to assist patients with resource allocation and choices
• Has freedom to determine how to best accomplish functions within established procedures
• Provides consultation to low risk guias on patients with significant or intensive community resources needs
• Participates in the development and maintenance of case management metrics
• Provides professional education to staff and community
• Other duties as assigned by Guia Manager

What You’ll Bring

Knowledge, Skills, and Abilities

• Experience managing the needs of Senior/Geriatric populations
• Experience assessing and addressing the social determinant of health
• Working knowledge of ICD-10 and Z codes
• Proficiency with EMRs, computers, mobile devices, medical devices, and Microsoft Office Suite
• Excellent therapeutic communication and negotiation skills in interactions with patients, families, physicians, and health care team colleagues
• Exposure and/or experience in pre-acute and post-acute care
• Expertise connecting patients and ensuring closed loop referral with community resources and governmental agencies that address complex social needs
• Ability 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) preferred
• Requires a Licensed Master Social Worker (LMSW) or equivalent 3-5 years of experience AND CHW certification plus 6- 8 years social work experience.
• Must have knowledge of government/community resources as well as Medicare, Medicaid, long-term care, or any other applicable resources/services
• Must have knowledge for transacting LIS, PAP, and SNAP applications and other foundation applications
• Must demonstrate critical 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.