Social Worker (LPC/LCSW)

Social Worker-Community Health Center

Join our mission to provide a comprehensive continuum of care for people in Louisiana, encompassing primary care, behavioral health, and substance use disorder treatment. Help save lives at OHL!

Job Summary

Odyssey House Louisiana, Inc. is seeking a full-time Social Worker for the Community Health Center. The schedule is Monday-Friday 8am-5pm. The Social Worker will provide comprehensive assessment and diagnosis of behavioral health clients. The position will also assist primary care providers and Program Managers with implementing disease management programs; participate in the development, review, and evaluation of the family and/or client’s plan of care; utilize information from various sources to identify patients who would benefit from disease management and case management services; educate and engage patients in their own care management; identify social and/or medical barriers that impede health outcomes; link patients to appropriate levels of care/appropriate and supportive services; work collaboratively with a multidisciplinary inter-agency team to facilitate achievement of desired treatment outcomes, monitor patient ED and hospitalization utilization rates; and utilize an Internet based care management system to track patient progress and health outcomes.

Responsibilities and Duties 

It is the duty and responsibility of the Social Worker to:

• coordinate/facilitate patient care;
• provide direct care to patients within the Scope of Practice for which the provider is licensed;
• provide direct care to clients/patients to support the agency’s department;
• manage patient care under Best Practices, UDS recommendations, and as prescribed to maintain accreditation;
• conduct thorough documentation of visits and medical orders to support billing charges;
• complete billing components of visit to optimize revenue within dictated time frames;
• work collaboratively and maintains communication with patient care team (providers, nurses, etc.) to provide effective, timely, and appropriate patient care management;
• assist patients and providers to adhere to evidence-based treatment protocols for specific disease states;
• educate patients and helps to engage them in their own care management, provide asthma and diabetes education;
• monitor patient care by tracking patient charts, counsel patients during physician visits, follow up through telephone calls and home visits as needed, and utilize Internet based case management tracking system;
• meet directly with patient/family to assess needs and develop an individualized care plan as necessary;
• ensure/maintain plan consensus from patient/family, physician, and health care team;
• collaborate with relevant community-based social services and health care organizations (social workers, home health care, school nurses, hospice providers, etc.) to address patient needs/barriers to improved health outcomes and to secure necessary care and equipment;
• address/resolve system problems impeding progress; proactively identify and resolve delays and obstacles to expedite care;
• utilize advanced conflict resolution skills as necessary to ensure timely resolution of issues;
• collaborate and communicate with multidisciplinary team at all phases of planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, and teaching and ongoing evaluation;
• identify patients with need for Patient Assistance Program submission to pharmaceutical companies in order to offset the cost to patient (This includes assisting patient in filling out application, identifying needed documents to support income, assure provider licenses are submitted, application is signed by provider, manage the course of application, notify patient of arrival of medicine, and when need for refills occurs; log of applicants will be kept and submission of application and arrival of meds will be documented in log);
• perform utilization management and quality screening for assigned patients;
• identify at-risk populations using approved screening tool(s) and follows established care and reporting protocols;
• monitor medical resource use on an ongoing basis and take action to achieve continuous improvement;
• refer cases and issues to PCP and follows up as indicated; follow up on referrals from PCP as appropriate;
• actively participate in clinical performance improvement activities;
• participate in development, implementation, evaluation and revision of disease management tools as a member of the clinical change team;
• attend local meetings as necessary;
• participate in training as necessary to successfully complete job responsibilities, including training in disease management protocols, care management strategies, use of network software programs, and data analysis skills;
• use data to drive decisions and plan/implement performance improvement strategies related to care management for assigned patients, including fiscal, clinical, and patient satisfaction data;
• collect special study data for specific performance and/or outcome indicators as determined by program;
• participate in discussions of key variances and outcomes that relate to areas of direct responsibility;
• use data in collaboration with other disciplines to ensure effective patient management;
• provide effective treatment planning and assist clients in successfully achieving goals;
• evaluate crisis situations and apply appropriate interventions;
• actively participate in meetings that support the integrated health care model to provide comprehensive care for clients;
• assist in the detection of “at risk” patients and development of plans to prevent further psychological or physical deterioration;
• assist the primary care team in developing care management processes including guidelines, disease management techniques, case management, and patient education to improve self-management of chronic disease;
• provide assessment, consultation, and brief intervention for psychological/psychiatric problems and/or disorders;
• teach patients, families, and staff, care, prevention, and treatment enhancement techniques
• monitor the site’s behavioral health program to identify and make improvement recommendations for problems related to patient service; and perform other duties as assigned.

Qualifications and Skills

Required:

Minimum qualifications include the following:

• Master’s in Social Work 
• LCSW unencumbered licensure 
• Greater than 1 year Clinical/UM/Discharge Planning/Home Care/Social Work/Ambulatory experience 
• Current CPR certification
• Excellent interpersonal, communication, and negotiation skills  
• Clinical competence in assigned area  
• Strong organizational and time management skills
• Ability to work independently
• Familiar with medication-assisted treatment and including opioid treatment programs.

Compensation and Benefits

Competitive compensation and benefits package includes insurance (health, dental, vision, life, long-term and short-term disability), leave benefits and 401k match.