Care Coordination Social Worker — Community Resources

Neighborhood-Family-Practice; Cleveland (OH); Sur place; USD 52 000 - 74 000; Plein temps

Résumé du poste

Neighborhood-Family-Practice seeks an experienced Social Worker to help patients and families access community resources, coordinate care, and address social determinants of health. You will collaborate with medical and behavioral health teams to improve patient well-being and reduce costs.

Responsibilities include care coordination, referral tracking, advocacy, documentation, and developing plans with patients and families. Evening/weekend flexibility and local travel may be required.

Qualifications

• Bachelor’s or Master’s Degree in Social Work required.
• Current, active LSW license to practice in Ohio.
• 3+ years’ experience in clinical, social service, or community resource setting; crisis intervention preferred.

Responsabilités

• Assess patient’s unmet needs and provide social work care coordination and linkage to services to improve health and reduce costs.
• Track referrals and assist in reducing barriers to services.
• Advocate for patients to access identified services.
• Maintain regular contact with patients, providers, and programs involved in care.
• Collaborate with patient, family, and providers to develop and monitor a plan of care.
• Document and report on patient services per organizational requirements.
• Ensure adherence to care plans and evaluate progress; support behavior change where needed.

Connaissances

Communication skills

Cultural sensitivity

Bilingual (preferred)

Care coordination

Formation

Bachelor’s or Master’s Degree in Social Work

Current LSW license (Ohio)

BLS certification

Outils

EPIC EMR/EHR

Microsoft Office

Database management

Description du poste

Neighborhood-Family-Practice seeks an experienced Social Worker to help patients and families access community resources, coordinate care, and address social determinants of health. You will collaborate with medical and behavioral health teams to improve patient well-being and reduce costs.

Responsibilities include care coordination, referral tracking, advocacy, documentation, and developing plans with patients and families. Evening/weekend flexibility and local travel may be required.