Social Worker - Primary Care

Social Worker - Primary Care

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The Social Worker is responsible for delivery of social work services to patients, including psychosocial evaluations, ongoing counseling, casework services, coordination of referrals, transitions, and potentially palliative care and bereavement services. These patients may have advanced illnesses and often have other complex medical/psychosocial/addiction issues. The Social Worker provides support and care for patients in various settings including: all types of patients’ home settings, assisted living residences, shelters, hospitals, emergency departments, skilled nursing facilities, clinics, and specialty settings.

NOTE: This position will cover NE Portland and St. John's area.

Estimated Hiring Range:

$44.26 - $54.09

Bonus Target:

Bonus - SIP Target, 5% Annual

Current CareOregon Employees: Please use the internal Workday site to submit an application for this job.

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Essential Responsibilities

• Conduct comprehensive psychosocial assessments and make appropriate referrals to community resources as well as provides education to patients and families regarding community resources, benefits and entitlements.
• Collaborate with clinical and support staff regarding patient/family/caregiver issues.
• Conduct patient and family counseling and education considering family system/dynamics and coping methods to all age groups and make appropriate referrals to other community resources if indicated.
• Help patient and family/caregiver develop coping strategies to manage declining physical health, and emotional or spiritual needs.
• Closely partner with patient providers and interdisciplinary care team across the continuum to facilitate care that meets the individual’s personal needs, values, and preferences.
• Provide short-term crisis intervention and assume active role of advocate for family.
• Assist clinicians and clinical teams with management of transitions of care when patients are moving from one setting to another, including (but not limited to) from place of residence to hospital or nursing home and back, assisting with placement as needed.
• Provide direct patient care support in a variety of settings.  For those working closely with advanced illness patients, the Social Worker will utilize palliative care principles, trauma informed care, motivational interviewing and case management strategies.
• Participate as a member of interdisciplinary care team assisting with establishing and implementation of psychosocial care plan in patients with serious, complex and/or chronic illness which could include partnering with Primary Care, Hospice or AIC team members.
• Assist patients and family with advance care planning which includes discussions about goals of care/treatment, answering general questions about power-of-attorney documentation, the POLST form and the Oregon Advanced Healthcare Directive Form.
• Communicate and coordinate with other providers to ensure care is coordinated and consistent with patient’s goals of care, including AD/POLST.
• Assist with establishment of POA-HC (power of attorney for health care) and with establishment of end-of-life care plans as needed.
• Provide education to patients, family members, caregivers and Housecall Providers’ staff regarding mental health issues, grief, resiliency, hospice services, community resources, benefits and entitlements.
• Provide consultation on ethical issues that arise for HCP staff.
• Conduct mental status exams (e.g., MMSE, SLUMS, MoCa) as requested by Providers.
• Provide advocacy for patients and families with various community agencies, care facilities and other institutions as needed.
• Assist clinicians with organization and/or facilitation of care conferences for assessment, education or conflict management.

Experience and/or Education

Required

• Master’s degree in social work from an accredited college
• Current Oregon LCSW, LMSW or CSWA license
• Minimum 1 year work experience in geriatrics, home health, hospice, hospital, primary care/specialty care clinic or other community based mental health or outreach social work
• Valid driver’s license, acceptable driving record, and automobile liability coverage or access to an insured vehicle
• CPR certification at hire or within 6 months in position

Preferred

• Experience dealing with substance use disorders, care coordination and needs assessment for high- risk populations

Knowledge, Skills and Abilities Required

Skills and Abilities

• Practice within the scope of license where applicable, and as required by law and regulation.
• Ability to assess psychosocial needs, establish and implement a social work plan of care, triage urgent and crisis situations, and stay focused
• Ability to be sympathetic to a patient, family or caregivers needs, and be able to deal with people in various states of pain, trauma and tragedy
• For those working with advanced illness patients, employees must feel comfortable supporting patients at the end of their life; including facilitating, evaluating and coaching advanced care planning conversations performed by AIC Team or other CO programs
• Ability to exercise sound clinical judgment, independent analysis, critical thinking skills and knowledge of medical and behavioral health conditions when identifying clients’ multidisciplinary needs, developing health goals and communicating with providers
• Must be a clear, timely and compassionate communicator and be able to maintain healthy boundaries
• Ability in case management and counseling with frail and complex patients
• Ability to communicate effectively with diverse staff and patients, their families and caregivers
• Able to establish therapeutic relationships with patients, families, caregivers and staff using effective communication
• Excellent interpersonal skills
• Ability to adhere to organizational standards, policies and procedures
• Ability to work both independently and collaboratively
• Ability to work under pressure to meet deadlines
• Ability to take initiative and utilize innovative techniques and ingenuity
• Ability to interact with various departments throughout the organization
• Ability to work flexible hours, if needed
• Must be organized and have the ability to plan, prioritize and coordinate multiple projects or tasks
• Must have general computer skills and a working knowledge of Electronic Medical Records systems, MS office, Outlook, and the internet
• Ability to work in an environment with diverse individuals and groups
• Ability to learn, focus, understand, and evaluate information and determine appropriate actions
• Ability to accept direction and feedback, as well as tolerate and manage stress
• Ability to see, read, hear, and speak clearly for at least 6 hours/day
• Ability push, pull, stand, sit, and perform repetitive finger and wrist movement to for at least 3-6 hours/day

• Ability to lift, carry, pinch small objects, walk, bend, and climb stairs for up to 3 hours/day
• Ability to operate a motor vehicle in all kinds of weather conditions

Working Conditions

Work Environment(s):         ☒ Indoor/Office    ☒ Community      ☐ Facilities/Security                       ☐ Outdoor Exposure

Member/Patient Facing:     ☐ No                        ☒ Telephonic       ☒ In Person

Hazards:  May include, but not limited to, physical and ergonomic hazards.

Equipment:  General office equipment

Travel:  Requires travel outside of the workplace at least weekly; the employee’s personal vehicle may be used. Driving infractions will be monitored in accordance with organizational policy.

Work Location: Hybrid-Community 2 days/week, member facing

Schedule:  This position may occasionally require more than 8 hours per day.

If you receive an offer of employment for this position, it is contingent on the satisfactory completion of a pre-employment background check, immunization review, and drug screen (including THC/Marijuana). CareOregon is a federal contractor and must comply with all federal laws.

We offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package.  Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. Housecall Providers offers medical, dental, vision, life, AD&D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.). We also offer a strong retirement plan with employer contributions. Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility. Non-benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks. Please contact your recruiter for more information.

We are an equal opportunity employer

Housecall Providers is an equal opportunity employer.  The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization.