Social Worker

To protect the health and well-being of our members, employees and community, CareOregon requires all employees to be fully vaccinated against COVID-19 or have an approved medical or religious exception as a qualification of employment.

Candidates who receive an offer of employment by CareOregon, must provide proof of COVID-19 vaccination or submit a medical or religious exception request, which will be evaluated in accordance with CareOregon’s standard accommodation process.

Position Title: Social Worker

Department: Primary Care

Title of Manager: Supervisor: Primary Care Clinical Manager

Supervises: Non-Supervisory position

Employment Status: Regular – Non-Exempt

Requisition ID: 20404

General Statement of Duties

The Social Worker is responsible for delivery of social work services to patients, including psychosocial evaluations, ongoing counseling, casework services, coordination of referrals, transitions, and potentially palliative care and bereavement services. These patients may have advanced illnesses and often have other complex medical/psychosocial/addiction issues. The Social Worker provides support and care for members in various settings including: all types of members’ home settings, assisted living residences, shelters, hospitals, emergency departments, skilled nursing facilities, clinics, and specialty settings.

Essential Position Functions

• Conducts comprehensive psychosocial assessments and makes appropriate referrals to community resources as well as provides education to patients and families regarding community resources, benefits and entitlements.
• Collaborates with clinical and support staff regarding patient/family/caregiver issues.
• Conducts patient and family counseling and education considering family system/dynamics and coping methods to all age groups and makes appropriate referrals to other community resources if indicated.
• Help patient and family/caregiver develop coping strategies to manage declining physical health, and emotional or spiritual needs
• Closely partners with patient providers and interdisciplinary care team across the continuum to facilitate care that meets the individual’s personal needs, values, and preferences.
• Provides short term crisis intervention and assumes active role of advocate for family.
• Assists clinicians and clinical teams with management of transitions of care when patients are moving from one setting to another, including (but not limited to) from place of residence to hospital or nursing home and back, assisting with placement as needed.
• Provides direct patient care support in a variety of settings. For those working closely with advanced illness patients, the Social Worker utilizes palliative care principles, trauma informed care, motivational interviewing and case management strategies.
• Participates as a member of interdisciplinary care team assisting with establishing and implementation of psychosocial care plan in patients with serious, complex and/or chronic illness which could include partnering with Primary Care, Hospice or AIC team members.
• Assists patients and family with advance care planning which includes discussions about goals of care/treatment, answering general questions about power-of-attorney documentation, the POLST form and the Oregon Advanced Healthcare Directive Form.
• Communicate and coordinate with other providers to ensure care is coordinated and consistent with patients goals of care, including AD/POLST
• Assists with establishment of POA-HC (power of attorney for health care) and with establishment of end-of-life care plans as needed.
• Provides education to patients, family members, caregivers and Housecall Providers’ staff regarding mental health issues, grief, resiliency, hospice services, community resources, benefits and entitlements.
• Provides consultation on ethical issues that arise for HCP staff.
• Conducts mental status exams (e.g., MMSE, SLUMS, MoCa) as requested by Providers.
• Provides advocacy for patients and families with various community agencies, care facilities and other institutions as needed.
• Assists clinicians with organization and/or facilitation of care conferences for assessment, education or conflict management.

Essential Department and Organizational Functions

• Maintain patient/family and staff confidentiality in compliance with HIPAA laws.
• Participate in the coordination of the patient’s care in accordance with professional standards of practice.
• Practice within the scope of license, certification or registration, where applicable, and as required by law and regulation.
• Develop and maintain professional boundaries with all patients/family/caregivers.
• Maintain agreed upon work schedule and meet deadlines for completion of work.
• Demonstrate the ability to function in a variety of care environments, including home settings, skilled nursing facilities, assisted living environment, etc.
• May provide after-hours coverage or weekend coverage as needed.
• Serve as an ambassador for CareOregon and Housecall Providers at all times.
• Demonstrates cooperation and teamwork and maintains collaborative relationships with all levels of staff and community partners.
• Participate in orientation of new employees, volunteers or students seeking experience in hospice.
• Attend staff and mandatory in-services meetings, as required.
• Participate in ongoing education and assume responsibility for updating professional skills.
• Familiar and comfortable with a person-centered approach to communication, education and care planning.

• Maintains patient and personal safety regarding occupational health and safety and participates in safety program, as requested.
• Participates in Quality Assessment Performance Improvement efforts to continually assess and improve quality of care, as requested.

Knowledge, Skills and Abilities Required

• Ability to assess psychosocial needs, establish and implement a social work plan of care, triage urgent and crisis situations, and stay focused
• Ability to be sympathetic to a member, family or caregivers needs, and be able to deal with people in various states of pain, trauma and tragedy
• For those working with advanced illness patients, employees must feel comfortable supporting members at the end of their life; including facilitating, evaluating and coaching advanced care planning conversations performed by AIC Team or other CO programs.
• Ability to exercise sound clinical judgment, independent analysis, critical thinking skills and knowledge of medical and behavioral health conditions when identifying clients’ multidisciplinary needs, developing health goals and communicating with providers
• Must be a clear, timely and compassionate communicator and be able to maintain healthy boundaries
• Demonstrated ability in case management and counseling with frail and complex patients
• Ability to communicate effectively with diverse staff and patients, their families and caregivers
• Able to establish therapeutic relationships with patients, families, caregivers and staff using effective communication
• Excellent interpersonal skills
• Ability to work both independently and collaboratively
• Ability to work under pressure to meet deadlines
• Ability to take initiative and utilize innovative techniques and ingenuity
• Ability to interact with various departments throughout the organization
• Ability to work flexible hours, if needed
• Must be organized and have the ability to plan, prioritize and coordinate multiple projects or tasks
• Must have general computer skills and a working knowledge of Electronic Medical Records systems, MS office, Outlook, and the internet
• Ability to adhere to organizational standards, policies and procedures

Education and/or Experience

Required:

• Master’s degree in social work from an accredited college
• Current Oregon LCSW, LMSW or ACSW license
• Valid driver’s license, acceptable driving record, and automobile liability coverage or access to an insured vehicle
• CPR certification at hire or within 6 months in position

Preferred:

• Minimum 2 years work experience in geriatrics, home health or hospice, or other community based mental health or outreach social work
• Experience dealing with substance use disorders, care coordination and needs assessment for high risk populations

Physical Skills and Abilities Required

Cognitive and Other Skills and Abilities Required

The following cognitive or mental requirements are necessary on a daily basis:

• Critical thinking
• Reading, writing, mathematics
• Drawing conclusions from written or computer generated materials
• Implementing recommendations by coordinating people and/or other resources
• Developing plans, procedures, goals, strategies or processes
• Clear verbal articulation
• Ability to tolerate and manage stress and grief

Working Conditions

• Environment: This position’s primary responsibilities typically take place in the following environment(s) (check all that apply on a regular basis):

Inside/office Clinics/health facilities Member homes

• Other_________________________________________

• Schedule: This position may occasionally require more than 8 hours per day.
• Travel: This position requires frequent travel outside of the workplace, in which the employee’s personal vehicle may be used. Driving may be required in all kinds of weather conditions. Driving infractions will be monitored in accordance with organizational policy.
• Equipment: General office equipment and/or mobile technology
• Hazards: OSHA Category I - Assigned tasks may involve exposure to communicable diseases, blood, body fluids or tissues.
• If you receive an offer of employment for this position, it is contingent on the satisfactory completion of a pre-employment background check and drug screen. CareOregon is a federal contractor and must comply with all federal laws.

Candidates of color are strongly encouraged to apply. CareOregon is committed to building a linguistically and culturally diverse and inclusive work environment

Veterans are strongly encouraged to apply.

Equal opportunity employer. This company considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.