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Wellforce Integrated Adult Behavioral Health Social Worker in Lowell, Massachusetts

As a Behavioral Health Social Worker will work closely with the patient/family, the primary care physician, and the health care team to help ensure that patients receive comprehensive and coordinated care through the continuum. They will help patients who have a behavioral health diagnosis and are at high risk for increased health care resource utilization. The goal is to increase patient and family engagement in their health care, to develop patient specific treatment plans and to assist them in navigating through the complex variety of health care system and connection to community resources. The Behavioral Health Social Worker will be integrated into one or more primary care practices and will work closely with community partners, as well as the other members of the Wellforce ACO Care Team, to develop the plan of care for the patient, monitor their adherence to it, and revise as needed.

Duties & Responsibilities

•Develops and implements individualized holistic care plans that will address patients’ unique needs with the goal of improved self-care and decrease need for urgent care for this behavioral health population.

•Identifies specific physical, emotional, educational and cultural needs of patients and completes an assessment including their functional, health, psychosocial and income status. Determines eligibility and appropriateness for community services or programs. Reports any signs or symptoms of neglect or abuse as mandated.

•Consults with the patient and family regarding how to meet his/her goals, and identifies and addresses any barriers to meeting the plan of care. Follows up as necessary to make sure the patient is meeting their goals. Educates patients on the levels of health care (homecare, acute rehab), community resources, and advance directives.

•Refers to and collaborates with outside agencies, facilities, payers, and other relevant community resources, such as community health workers, to refine the plan of care to meet the changing needs of the patient and connect to addiction treatment programs as needed.

•Develops trusting, professional, caring relationships with patients and families, engaging respectfully and with utmost attention to service.

•Contacts patients telephonically on a regular basis to assess their progress and revise the plan of care as needed. Ensures communication and understanding of treatment plan among the patient, family and health care team members.

•Regularly perceives potential problem situations and intervenes to offset adverse impact, demonstrates proactive attitude. Utilizes established protocols and collaborates with health team to facilitate therapeutic interventions and attainment of desired patient outcomes. Advocating for patient and caregiver needs in inpatient, outpatient, home, and community settings.

•Maintains collaborative, team relationships with peers and colleagues in order to effectively contribute to the ACO’s achievement of goals, and to help foster a positive work environment. Maintains compliance with all mandated regulations of state and federal agencies. Committed to pursuing excellence in improving the health status of the community and demonstrates professionalism as well as respect and dignity for patient, caregivers and all members of the health care team.

Qualifications

•Social Worker Licensure to practice in Massachusetts is required

•5 years of experience as a Social Worker preferred

•Experience in performing the role as a Behavioral Health Coordinator, or a similar community role, skilled nursing facility or physician’s office

•Knowledge of community programs, behavioral health providers, and addiction treatment programs •Excellent interpersonal, conflict resolution, and communication skills telephonically as well as face-to-face

•Demonstrates ability to work well with people of various ages, backgrounds, ethnicities, and life experiences

•Ability to work independently with minimal supervision and as part of a team •Experience with Electronic Medical Records and possess a willingness and ability to learn and utilize new technology and procedures that will continue to develop in their role and throughout the organization •Detail oriented, with strong organizational skills and multi-tasking abilities •Very strong working knowledge and proficiency with technology and business software (Microsoft Office) •Must have reliable transportation for local travel and a valid driver’s license •Fluency in second language preferred but not required

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