The Social Worker Care Navigator is accountable for assuring a high standard of quality and coordination of care, in support of HealthONE value based care (VBC) programs with payers in the market. The SW is responsible and accountable for assessing the psychological, social, emotional, cultural and/or financial needs that influence high-risk patients' health and recovery. Has the ability to utilize social service, supportive counseling, and clinical knowledge in the assessment of these needs. Has a defined role, working in an advisory capacity to the RIHN practices, creating and monitoring standards of care, and providing overall support of the VBC programs.
DUTIES INCLUDE BUT NOT LIMITED TO:
Identification, outreach and follow up in regards to patients that are high risk, have a gap score and gaps in care.
Outreach to patients to ensure follow up visit with their PCP post inpatient or ER visit to the hospital.
Complete the key interventions pertinent to patient care and follow up needs.
Collaborate with the payer systems and payer Care Coordinators on specific patient care needs.
Provide patient education relative to the patient's diagnosis and treatment plan.
Outreach to patients to encourage them to work with their applicable payer Case Manager, Disease Manager or Wellness Program designee.
Meet with payers in joint governance and other VBC meetings.
Review reports from payers and assist Director of Quality in the interpretation of the reports and actions needed
Obtains and analyzesquality metricsand reports for care opportunities, supports practice implementation of care coordination and care management, identifies action plans for providers to implement to improvecost, quality and the patient experience and participates in design,development and implementation of community learning forums.
Test and pilot new VBC initiatives and work with leadership on refining processes, helping HOPP achieve contractual metrics.
Work with management on communication to physicians regarding available patient care programs through the VBC programs- both written/email communication and visits to provider meetings as necessary.
Conduct practice needs assessment in order to learn more about practice demographics, their daily operations and current workflows.
Collaborates with Primary Care Team to meet providerand practice needs.
Supports the efforts of providersand practice teams on office based care delivery interventions resulting in cost of care savings and improvedhealth outcomes for patients.
Provides education for practicesto develop expertisewith metrics and data reviewfor quality improvement.
Shadow and/or train physicians and medical staff as necessary in clinical workflows and coordination of care to improve clinical quality and achieve VBC goals.
Assist in the development, implementation and monitoring of corporate and/or HealthONE policies and procedures as they relate to VBC programs.
When the need arises, will perform other duties as assigned by supervisor.
Maintenance of an LCSW license within the State of Colorado preferred;
Masters of Social Work required
Competence in the ability to triage patients over the phone and in person;
Ability to analyze payor quality data and navigate reports from various Electronic Health Records
Managed Care Understanding specifically ACO/Value Based Contracts
Public speaking centered around medical practice education
Commitment to collaboration, professionalism, and effective communication in all interactions with physicians, HealthONE Physician Services employees, patients, caregivers and payers.
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