Social Work Liaison: Bilingual (Community health work)

JOB SUMMARY:
The Social Work Liaison provides support to patient as a part of Rhode Island Primary Care’s (RIPCPC) interdisciplinary care team. Social Work Liaison’s work with their assigned primary care and pediatric practices to respond to the social and emotional needs of the patients. RIPCPC care management team focuses on quality care, patient advocacy, and interdisciplinary support. The Social Work Team works to promote wellness, increase patient knowledge, and improved patient outcomes in a patient-centered approach.

ESSENTIAL JOB FUNCTIONS:

General Responsibilities:

· Work with patients on resource coordination and brief case management to address social determinant of health needs and connection to behavioral health resources

· Work collaboratively with practice office staff and physicians

· Work collaboratively with RIPCPC staff including and not limited to, nurse care managers (NCM), pharmacists (RPh), referral coordinators, and quality improvement specialists (QIS) team members

· Active participation in staff meetings as scheduled and education sessions as needed

· Complete documentation of outreach following work flow based on patient task

Care Management Support:

· Assess needs related to social determinants of health and emotional wellness

· Assist with setting up social service support including and not limited to,

• food assistance (Meals on Wheels, SNAP)
• housing transitions (housing applications, emergency housing needs)
• state and federal aid applications, insurance & benefits (Medicaid, Medicare)
• social opportunities (Senior Centers, Adult Day Health Centers, local community opportunities)
• long term care resources (assisted living or nursing home, in-home care, memory and safety concerns)
• child and family services (HBTS, PASS, day programs)
• emotional (psychoeducation around symptoms, coping strategy and safety planning)

· Collaborate with BH Clinicians and referral coordinators to best triage and meet patient needs

· Assist patients in managing activities of daily living that impact their functioning, ability to adhere to health routines, and overall satisfaction and health

· Support patients in increasing readiness to access community or behavioral health resources

· Support patients transitioning from different levels of care (partial hospitalization programs, residential treatment, outpatient treatment)

· Provide outreach following discharges from emergency department visits or inpatient hospitalizations to support after-care plan

Provider and Practice Support:

· Work with assigned practices including office staff, assigned members of RIPCPC care team, and providers to establish workflows related to patient care, coordination, communication, etc.

· Navigate various electronic health records (EPIC, ECW, Amazing Charts) that RIPCPC providers utilize

· Provide consultation and support to practices and interdisciplinary teams around behavioral health and social resources, strategies for engaging around social and emotional needs, etc.

· Serve as behavioral health triage for providers/practices around behavioral health resources, coordinate with referral coordinators to support patients to engage with appropriate levels of care

QUALIFICATIONS:

Minimum Education and Experience:

· Bachelor’s degree, Social Work preferred

· 3-5-year work experience in behavioral health or social work services

· Experience with Microsoft Office – Excel, PowerPoint, Word

· Experience with documenting in an electronic health record

· Effective oral and written communication skills

· Skilled in patient engagement strategies and techniques

· Skilled in telephonic and in-person patient interactions

· Highly self-motivated

· Flexibility and ability to shift work prioritization based on need

· Solid understanding of healthcare system and how to assist patients in navigation

Preferred Education, Additional Qualifications and Experience:

· EPIC Trained

· Bilingual – Spanish preferred (this vacancy is in the Pawtucket area serving Spanish and Portuguese speaking populations)

· Experience working in interdisciplinary teams

· Good knowledge of social and behavioral health resources across the state

· Reliable car to travel amongst various offices in a geographical area of the state

COVID Update: Job is currently hybrid between remote (from home), Cranston office, home visits, and provider offices. Vaccinations are required (medical exemptions allowed per DOH).

What RIPCPC Does...

Rhode Island Primary Care Physicians Corporation (RIPCPC), is a multi-specialty Independent Practice Association (IPA) that has been implementing innovative quality improvement models since 1994. We are a population health management organization that focuses on improving outcomes for our physician members’ patients. Our dedication to improving the care delivery system is demonstrated through our commitment to the National Committee for Quality Assurance’s Patient-Centered Medical Home (PCMH) model. A patient centered approach to practicing medicine enhances quality, improves access and implements advanced care coordination strategies. RIPCPC has implemented more PCMH’s than any other organization in Rhode Island. In addition to the proliferation of the PCMH, our latest and most significant initiative is focused on shaping a virtually integrated health care system with Care New England. This joint venture has led to the creation of an Accountable Care Organization (ACO), Integra, Rhode Island’s first partnership between a physician organization and a hospital system. Integra’s unique ability to coordinate care system wide, enables us to deliver a care experience unmatched in Rhode Island. Our Mission: Deliver the highest quality of health care and the best patient experience in the State of Rhode Island.

Rhode Island Primary Care Physicians Corporation is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.

Job Type: Full-time

Pay: $19.00 - $23.00 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Supplemental Pay:

• Bonus pay

Education:

• Bachelor's (Preferred)

Language:

• Bilingual (Preferred)

License/Certification:

• Driver's License (Preferred)

Work Location: Multiple Locations