ChenMed is transforming healthcare for seniors. We provide big answers to big problems in health care delivery. ChenMed is a full-risk primary care market leader with an innovative philosophy, unique physician culture and end-to-end customized technology. These things allow us to provide world-class primary care and coordinated care to the most vulnerable population – moderate- to low-income seniors who have complex chronic diseases.
Through our innovative operating model, physician-led culture and empowering technology, we are able to drive key quality and cost outcomes that create value for patients, physicians and the overall health system. Our model allows us to practice medicine the way it should be practiced. By recruiting focused physicians and reducing their doctor-to-patient ratios, we increase patients’ “face time” during each monthly appointment and help foster stronger doctor-patient relationships. Our model also drives and enhances compliance with treatment plans.
As a result of our efforts, our patients realize lower hospital admissions. Their overwhelming response to our approach is reflected in our aggressive, organic growth and net promoter scores in the low to mid 90s, which is unheard of in any industry. Read more about our results and the value of the ChenMed model.
As a company, we are making a difference in the lives of seniors and the health care system overall.
ESSENTIAL JOB DUTIES/RESPONSIBILITIES:
Assessment and Diagnosis:
Conducts timely and appropriate assessment, prioritizing patients on the PCP’s High Priority Patients (HPP) and Top 40 patient list. Assesses patients for behavioral, psychosocial, financial, family issues, palliative care/end of life issues, home safety, etc. that contribute to hospitalization.
Dialogues with PCPs in order to support and advise concerning behavioral health (BH) disorders.
Identifies, manages and coordinates appropriate BH treatment planning and interventions, prioritizing patients on the PCP’s HPP and Top 40 patient lists.
Serves as a linkage between PCPs, outside BH providers, and patients to improve coordination of services and information flow.
Can assist with obtaining community resources or refer to in house Community Social Worker when available and appropriate.
Provides self-management support and ongoing phone contact with patients.
Inpatient Psych Care Coordination:
Coordinates and manages the needs of behavioral health patients who are hospitalized through the internal EMR (“HITS”) High Priority Patient (HPP) registry.
Maintains communication with other healthcare team members by attending appropriate meetings (i.e. weekly Super Huddles and Transitional Care Team meeting.).
Provides clinical consultation in an integrated health care environment regarding behavioral health diagnosis and needs, family interactions, social determinants of health, and BH community resources.
Maintains timely, accurate, thorough and appropriate documentation/reports per company policies and procedures. Initial biopsychosocial assessments will be completed within 48 hours. All follow up visits phone calls and collaborative contacts will be documented within 24 hours. LCSW/BHS will assure documentation meets billing guidelines.
Maintains LCSW state licensure by meeting yearly requirements. Attend behavioral health training seminars/continuing education to maintain current state LCSW License. ChenMed/JenCare/Dedicated provides 5 CEU days for this purpose to LCSW/BHS.
Provides clinical supervision for market Social Worker as requested.
Additional duties and responsibilities may include:
Connecting patients with mental health and/or community resources in order to help them maintain an optimum level of health.
Performs other duties as assigned and modified at manager’s discretion.
KNOWLEDGE, SKILLS AND ABILITIES:
Highly-developed business acuity and acumen
Full knowledge, understanding and comprehension of general Clinical Social Worker functions, practices, processes, procedures and techniques
Expertise in a variety of evidence-based behavioral health modalities needed for clinical diagnosis and treatment
Knowledge of counseling techniques used in individual, family and group treatment, as well as principles of social welfare
Knowledge of evidence-based behavioral health methods and techniques used in individual, family and group therapy as related to mental health and/or substance abuse issues in a primary care setting.
Knowledge of normative changes (e.g., sensory, cognitive, psychosocial) associated with aging for high-risk patients
Knowledge of advance care planning and palliative care, and related skill in addressing advance care planning with patients and/or their family systems
Ethical practice behavior consistent with ChenMed/JenCare/Dedicated policies and professional standards
Skill in psychosocial interventions with caregivers/family systems of high-risk patients
Teamwork skills in care coordination with patients, family systems, internal staff, and external providers
Appropriate utilization of community-based resources
Ability to work autonomously is required
Ability to monitor, assess and record patients’ progress and adjust accordingly
Ability to communicate technical information to non-technical personnel, and with patients and/or their family systems
Strong interpersonal, communication and critical thinking skills and the ability to work effectively with a wide range of constituencies in a diverse community
Demonstrated ability to provide care effectively and sensitively to people from different cultural groups
Ability to create a collaborative relationship to maximize the patient’s/family’s ability to make informed decisions.
Proficiency in written communication: documentation is clear, concise, and accurate, provides meaningful communication and is consistent with policy and regulatory requirements.
Proficiency in technology, including the utilization of Electronic Medical Record platforms for care coordination.
Proficient in Microsoft Office Suite products including Word, Excel, PowerPoint and Outlook, plus a variety of other word-processing, spreadsheet, database, e-mail and presentation software
Ability and willingness to travel locally, regionally and nationwide up to 50% of the time
Spoken and written fluency in English
This job requires use and exercise of independent judgment
At ChenMed, If you are an innovative, entreprenuerial minded, over-achiever who is extremely passionate in helping people and revolutionizing Healthcare again, we are that dynamic and exciting company you are looking for!
After applying, we encourage you to "follow" us on LinkedIn (ChenMed) as well! This way you can stay informed and up to date on what’s happening around our organization and start your path to becoming part of our FAMILY!
EDUCATION AND EXPERIENCE CRITERIA:
Master’s Degree of Social Work (MSW) required
A minimum of 2 years’ experience working with behavioral health clients providing direct evidence-based assessment, diagnosis formulation, treatment planning, treatment intervention and education to patients and/or family members required
A minimum of 2 years’ experience in a behavioral health primary care setting preferred
Licensed as a Clinical Social Worker (LCSW) required
Registration in State of employment may be required, if applicable, LCSWs must be compliant with their state mandatory laws of LCSW licensure renewal by participating and receiving their continuing education hours yearly
The Licensed Clinical Social Worker (LCSW)/Behavioral Health Specialist (BHS) is a member of the care treatment team including the PCP, other Medical Specialists, Social Worker, and Case Managers. The incumbent in this role provides direct assessment, diagnosis formulation, treatment planning and intervention to patients who have chronic, life threatening or altering diseases and disorders, and education to patients and/or families. He/She advocates for services and resources for the underprivileged and victims of abuse, neglect or other difficult personal situations. The LCSW/BHS adheres to strict departmental goals/objectives, standards of performance, quality patient care compliance, and policies and procedures as defined by industry standards and the enterprise.