Field Social Worker in Houston, TX

Explore opportunities with WellMed, part of the Optum family of businesses. We believe all patients are entitled to the highest level of medical care. Here, you will be part of a team who shares your passion for helping people achieve improved health outcomes. Explore rewarding opportunities for physicians, clinical staff and non-patient-facing roles. Join us and discover the meaning behind Caring. Connecting. Growing together.

The CareCoach Connect Social Worker is responsible for the assessment, planning, coordination and oversight of services for identified patients. The position identifies, evaluates, and provides management of services for patients with complex, catastrophic, Social Determinants of Health and/or psychosocial issues to promote quality, effective outcomes throughout the care continuum. The position ensures compliance with state and federal health plan requirements, Medicare guidelines and standards. The social worker acts as a liaison to coordinate and collaborate care with physicians, family, and other providers while always remaining an advocate for patients, putting them at the center of care delivery. The Social Worker will interact and engage with others as an interdisciplinary team member.

Primary Responsibilities:

• Performs comprehensive evaluations and documents findings in a concise/comprehensive manner that is compliant with documentation standards for the Center for Medicare and Medicaid Services (CMS)
• Performs patient assessments telephonically, virtually, or in the patient's home as needed
• Understands and plans to assure services provided work within the boundaries of the patient's plan eligibility. Coordinates identified patient's needs utilizing federal, state, and local community resources, as available
• Coordinates with external and internal teams to minimize obstacles and increase in patient and provider satisfaction
  • Actively participates in staff and Interdisciplinary Team (IDT) meetings
  • Adheres to organizational and departmental policies and procedures
  • Maintains a high level of professionalism and adheres to the WellMed Core Values
• Assumes responsibility for personal and professional development
  • Ensures licensure, certifications, and annual training are maintained and compliant
  • Maintains knowledge of current health plan benefits
• Conducts advanced care discussions with a patients and their families and properly documents their wishes in the electronic medical record
• Exhibits professionalism and is courteous with all patients, physicians and co-workers
• Follows CareCoach Connect providers' orders regarding the scope and frequency of services needed based on acuity and patient/family needs
• Maintains a patient case load, daily visits and point of care documentation levels as per standards
• Documents in the electronic health record progress toward established goals as per standards
• Performs other duties as assigned

• Bachelor of Social Work with a minimum of 3 years experience beyond the required years of experience
• Current BLS certification or must obtain certification within 30 days of employment hire date
• 3+ years social work experience in a health care environment
• Proficient in MS Office Suite to include Word, Excel, Notes, Outlook, and other departmental specific programs/applications
• Able to prioritize, plan, and handle multiple tasks/demands simultaneously
• Ability to travel locally up to 75% of the time
• Reliable transportation for daily travel to various locations as assigned
• Valid drivers license within the state of work
• This position requires Tuberculosis screening as well as proof of immunity to Measles, Mumps, Rubella, Varicella, Tetanus, Diphtheria, and Pertussis through lab confirmation of immunity, documented evidence of vaccination, or a doctor's diagnosis of disease

• Masters of Social Work with licensure (LMSW or LCSW or LBSW)
• Knowledge of disease management, managed care, medical terminology, referral process, claims, and CPT coding
• Experience working with geriatric and behavioral and mental health patient populations
• Long Term Care experience
• Bilingual (English/Spanish) language proficiency
• Excellent oral and written communications skills
• Solid organizational skills

• Ability to lift up to 50 pounds
• Ability to push or pull heavy objects using up to 100 pounds of force
• Ability to stand for extended periods of time
• Ability to use fine motor skills to operate equipment and/or machinery
• Ability to receive and comprehend instructions verbally and/or in writing
• Ability to use logical reasoning for simple and complex problem solving
• Occasionally requires exposure to communicable diseases or bodily fluids