Ambulatory Social Work Case - Harvard University
Cambridge, MA
About the Job
Basic Qualifications
- Master’s degree or equivalent work experience required
- Minimum of 5 years’ relevant work experience
Additional Information
Duties and Responsibilities continued:
- Assists HUHS patients and their families coordinate medical, social, emotional, insurance, and vocational issues related to injury or illness.
- Educates patients and families regarding Advance Directives and assists patients and families in completing Advance Directives.
- Promotes effective communication with hospitals and their departments. Educates them to resources available at Harvard University Health Services.
- Participates in/attends IM Team Meetings and daily huddles.
- Participates in/attends HUHS committees/work groups when appropriate.
- Communicates with primary care clinician, patient, and home care provider to ensure medically necessary services. Regularly communicates with patients requiring post- discharge service to assess patient satisfaction and that appropriate services are in place.
- Evaluates utilization and effectiveness of Home Care provider network.
- Assess quality of care of Home Care providers as well as responsiveness. Addresses areas of concerns with manager to ensure optimal quality of care for patients.
- Educates patients/families about non-skilled services for patients when necessary. Assists in arranging for these services when patients/families allow.
- Acts as a liaison between patients and HUHS to assist in coordinating follow up services.
- Ensures the department maintains effective communication with other HUHS Departments.
- Educates HUHS staff about Care Coordination’s scope of service and how to utilize HUHS case managers as resources.
- Identifies areas of improvement; recommends and implements solutions.
- Actively participates in project development. Collaborates with manager to implement, evaluate, and support programs to maximize utilization of available resources.
- Assists in maintaining a Quick Reference Resource Guide.
- Educates patients/families/caregivers as to trajectory of certain disease processes and level of support/care needed throughout disease process.
- Educates patients/families about health insurance processes and when appropriate benefits. Directs patients/families where to learn more about health insurance benefits.
- Provides supportive counseling to patients and families to enhance coping skills and resolve concerns.
- Provides supportive counseling to patients and families considering changes in living situations or managing changes related to a medical condition.
- Collaborates when appropriate with BCBS MA Nurse Case Manager in case management of HUSHP/HUGHP patients with complex medical and psychosocial needs.
- Develops a comprehensive treatment plan. Monitors and assesses appropriateness of treatment plan and makes appropriate modifications as necessary.
- Communicates with PCP or treating clinician on areas of concern in addition to ongoing updates on clinical progress.
- Reports incidences of suspected abuse and neglect of children, elders, and individuals with disabilities to appropriate designated state agency.
- Organizes and participates in patient case conferences as needed Provides timely, appropriate, comprehensive clinical documentation in patient's electronic medical record.
- Gives appropriate notice to manager when unexpected circumstances call for staff member to be away
- Participates in the orientation of new staff members.
- Identifies own learning needs and requests assistance from others when needed.
- Works independently, as well as collaboratively, with all members of the health care team.
- Treats patients with dignity, respect, and compassion.
- Provides prompt care/service and behaves sensitively in all interactions.
- Utilizes team leader as appropriate for clinical consultation and to apprise of legal, ethical, risk issues that may affect the patient, family, or health services.
Source : Harvard University