**Experienced Full Stack Case Management Social Worker - High Risk Program for Virtual Primary Care Delivery**

About One Medical at Home

One Medical at Home is a pioneering healthcare organization that is revolutionizing the way primary care is delivered. Our mission is to provide accessible, comprehensive, and coordinated care to patients across multiple states and markets. We are a fast-paced, forward-thinking company that is committed to building a better model of healthcare delivery. Our High Risk Care programs support the most medically complex and often homebound patients through a care continuum consisting of primary care house calls, care transitions management, and social services support programs.

The Opportunity

We are currently seeking a highly skilled and experienced Case Management Social Worker to join our One Medical at Home program within One Medical High Risk Care. This is a fully remote role that requires a strong and diverse skillset in relevant areas to drive success. As a Case Management Social Worker, you will play a key role in assessing and developing comprehensive care plans that address the biopsychosocial barriers to a patient's goals. You will provide complex case management to address Social Determinants of Health (SDOH) through partnering with patients, their caregivers, and their broader care network.

Key Responsibilities

• Advanced Care Planning / Long Term Care Planning:
  • Guide patients and families in making realistic health care decisions based on personal goals of care and clinical health prognosis
  • Serve as intermediaries between healthcare providers and patients to ensure comprehensive ACP discussions occur, including choosing surrogate decision makers
  • Assess for appropriateness of, and interest in, palliative care or hospice services, in the presence of serious illness
  • Facilitate discussions between patients and families around long term care planning in anticipation of potential functional decline
  • Improve patient/family knowledge and understanding of long term care planning and assist patients in understanding care options for future need
  • Link patients to the appropriate state and community services (Medicaid, SNAP, etc.) to carry out a realistic long term care plan
• Longitudinal Complex Case Management / Resource Navigation:
  • Establish effective virtual, supportive and engaging relationships, to proactively manage a panel of up to 300 patients with complex, chronic medical conditions
  • Collaborate with patients and caregivers to capture economic and social conditions (SDOH) that influence patients' health status
  • Partner with, and advocate for, patients to help overcome physical, financial, and emotional burdens related to SDOH and chronic disease management
  • Work with patients and caregivers to understand barriers to accessing appropriate care and, together with the One Medical at Home team, develop a plan to overcome obstacles as possible. Follow through, as appropriate, to make sure the plan is working as anticipated and adjust as needed
  • Ensure patients are referred to the appropriate community agencies and resources as needed, such as APS, Alzheimer's Association, American Cancer Society, Area Agency on Aging, Home Health, Meals on Wheels, Hospice, etc.
• Transitions of Care:
  • In conjunction with the RN, collaborate with key external multidisciplinary teams when a high risk patient is in a transition of care, to ensure the admission and/or discharge is on track, and work to resolve any barriers to successful discharge
  • With the OM at Home team, refer and connect the patient to in-home services such as home health care, physical therapy, food/meal delivery, and hospice care
  • Help patients and families navigate the healthcare system
  • Facilitate placement in facilities (i.e. nursing facilities, assisted living homes, rehabilitation centers, and drug treatment programs)
  • Build strong relationships with health systems, facilities, and post acute services (home health, hospice, etc.), including facilitating coordination and communication channels
• Psychosocial Support:
  • Assist families to cope with difficult situations such as housing instability, financial hardships, illness, or death
  • Promote and sustain an ethical culture of safety
  • Provide conflict mitigation and/or mediation with patient and family or social systems, within the context primary care
  • Assist care teams in understanding and setting appropriate boundaries when providing interventions and support
  • Empower team members to understand the role of cultural competence in providing equitable care

What You Will Need

To be successful in this role, you will need:

• Licensed Master of Social Work (LMSW): required with ability to achieve reciprocity to cover additional state markets within a year of employment
• 3+ years of experience as a Licensed Social Worker: with demonstrated experience in high risk, complex care settings, senior health, and/or case management experience
• Master of Social Work (MSW): required
• Experience with home based care services, hospitals/ SNF and long term care facilities: preferred
• Demonstrated skill in biopsychosocial assessments, resource navigation, care plan development, and coordination across healthcare settings on behalf of very complex patient needs: required
• Experience with Advanced and Long Term Care Planning: including ability to facilitate discussions around making realistic health care decisions based on patients' personal goals of care and in anticipation of potential functional decline
• A goal-oriented, high energy, passionate perspective: with a focus on living organizational values, and ability to set the tone for a positive work environment
• Exceptional capacity to multitask in a fast-paced, fast-growing environment: required
• Demonstrates outstanding critical thinking under pressure: using sound judgment in caring for patient needs
• Comfortable operating in ambiguity: and uses flexibility and creativity to address challenges
• Ability to use core coaching and teaching techniques: including patient-centered communication to activate and empower patients and families
• Experience working with Texas based resources (Medicaid Long Term Care, SNAP, LEAP): preferred
• Curiosity and ability to research and develop programs in markets outside of the Texas area: required
• High proficiency with Mac iOS and Google suite: required
• Strong preference for fluency in Spanish: preferred

Benefits

We offer a comprehensive benefits package to support your health and wellness, including:

• Paid sabbatical for every 5 years of service: to help you recharge and refocus
• Employee Assistance Program: free confidential advice for team members who need help with stress, anxiety, financial planning, and legal issues
• Competitive Medical, Dental and Vision plans: to keep you and your family healthy and protected
• Free One Medical memberships: for yourself, your friends and family
• PTO cash outs: option to cash out up to 40 accrued hours per year
• 401K match: to help you save for your future
• Credit towards emergency childcare: to help you balance work and family responsibilities
• Extra contributions toward maternity and paternity leave: to support you and your growing family
• Paid Life Insurance: One Medical pays 100% of the cost of Basic Life Insurance
• Disability insurance: One Medical pays 100% of the cost of Short Term and Long Term Disability Insurance
• Malpractice Insurance: malpractice fees to insure your practice at One Medical is covered 100%
• Reimbursement for costs associated with renewing or obtaining necessary state licenses: to support your professional development

Career Growth Opportunities and Learning Benefits

We are committed to helping you grow and develop your skills and expertise. As a Case Management Social Worker, you will have opportunities to:

• Develop your skills in advanced care planning and long term care planning: through training and mentorship
• Improve your knowledge of social determinants of health and resource navigation: through ongoing education and training
• Enhance your ability to work with complex patient populations: through case management and care coordination
• Build strong relationships with healthcare providers and community agencies: through collaboration and coordination
• Participate in quality improvement initiatives: to improve patient outcomes and satisfaction

Work Environment and Company Culture

We are a fast-paced, forward-thinking company that is committed to building a better model of healthcare delivery. Our company culture is centered around:

• Collaboration and teamwork: we work together to achieve our goals and support each other in our roles
• Continuous learning and development: we are committed to ongoing education and training to improve our skills and expertise
• Patient-centered care: we prioritize the needs and preferences of our patients and families
• Compassion and empathy: we strive to create a supportive and inclusive environment for all patients and team members

How to Apply

If you are a motivated and experienced Case Management Social Worker who is passionate about delivering high-quality care to complex patient populations, we encourage you to apply for this exciting opportunity. Please submit your resume and cover letter to [insert contact information]. We look forward to hearing from you!