Case Management Social Worker - High Risk Program (TX license required) at One Medical

The Opportunity:  

We are currently seeking a full time Social Worker to join our One Medical at Home program within One Medical High Risk Care. This is a fully remote role and is intended to serve patients virtually across multiple states and One Medical markets. The High Risk Case Management Social Worker will serve as a key member of the interdisciplinary team in conjunction with other members (Practitioners, Health Coaches, Nurses, Behavioral Health Specialists, etc.) to provide accessible, comprehensive, coordinated primary care based on longitudinal healing relationships. The Social Worker’s primary responsibilities center around assessing and developing a comprehensive care plan that addresses the biopsychosocial barriers to a patient’s goals. They provide complex case management to address Social Determinants of Health (SDOH) through partnering with patients, their caregivers, and their broader care network. The Social Worker facilitates difficult discussions around goals of care, advanced care planning, and links patients to state and community resources to improve overall health outcomes.  

One Medical Senior Health has a network of primary care practices that seeks to proactively provide the support patients need to live their fullest lives. Our practices offer smaller panel sizes and the opportunity to lead systemic change in health care delivery. The High Risk Care programs support the most medically complex and often homebound patients through a care continuum consisting of primary care house calls (One Medical at Home), care transitions management, and social services support programs. We are a fast-paced, fresh-thinking, high-growth company, building a better model of health care delivery.

What You Will Work On:

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. 
• Support clinic care teams in executing the care plan, including navigating community referrals, once a patient moves out of the High Risk Team

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
• Directly advocate on behalf of the patient by facilitating communications with healthcare providers, to ensure the patient’s right to self-determination 

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:

• 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
• 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
• 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)
• Curiosity and ability to research and develop programs in markets outside of the Texas area
• High proficiency with Mac iOS and Google suite
• Strong preference for fluency in Spanish

Physical Space Requirements:

• HIPAA compliant area within home that is secure, quiet and isolated from others to protect PHI
• Reliable internet connection

Benefits designed to aid your health and wellness:

Taking care of you today

• Paid sabbatical for every 5 years of service
• 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
• Free One Medical memberships for yourself, your friends and family
• PTO cash outs - Option to cash out up to 40 accrued hours per year

Protecting your future for you and your family

• 401K match
• Credit towards emergency childcare
• Extra contributions toward maternity and paternity leave
• 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

 Supporting your professional career

• 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

This is a full-time, virtual/remote role that requires a TX state license.

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