Medical Social Worker Care Coordinator

POSITION Title:               MEDICAL SOCIAL WORKER CARE COORDINATOR

FLSA Status:                      Exempt

Reports to:                   Sr. Operations Manager for Patient Advocacy & The integrated Behavioral Health Program

DEPARTMENT:                Integrated Behavioral Health Services

WORKSITE:                       All RFHN sites

MISSION

The mission of Ravenswood Family Health Network (RFHN) is to improve community health by providing culturally sensitive, integrated primary and preventive health care to all, regardless of ability to pay or immigration status, and collaborating with community partners to address the social determinants of health.

POSITION Summary

The Medical Social Worker Care Coordinator, under the administrative direction of the Sr. Operations Manager for Patient Advocacy & the Integrated Behavioral Health Program and the Integrated Behavioral Health and Social Services Director, is a key staff member who will provide vulnerable patients and their families with the resource support needed to achieve their health and mental health care goals.  We're looking for an MSW Care Coordinator to help bridge primary care and mental health on our integrated care team. You'll provide coaching, screening and/or clinical assessment, and short-term behavioral intervention directly to patients, working alongside and leading a small team of coordinators.

This role is for someone confident making independent judgment calls, who displays critical thinking and flexibility, learns quickly, builds trust with a multidisciplinary team, and is always ready to advocate for our patients.

Duties and ResponsibilitieS

To be performed in accordance with RFHN Policies and Procedures

- Work alongside and serve as the lead of the program’s care coordinators to support their work and provide additional guidance within their scope.

- Facilitate clear, complete, and professional warm handoffs between medical staff and behavioral health services.

- Collaborates effectively with multiple departments including Social Services, Health Coaches, Nurses, Health Care for the Homeless, and other medical departments.

- Educating clients and families about mental health, coping strategies, and available services.

- Helps patients and families effectively navigate RFHN and community resources.

- Provides timely crisis intervention and screening of high-risk patients grounded in a strength-based, empowerment-focused approach.

- Advocates without hesitation using motivational interviewing to help patients push past barriers to care.

- Attends and contributes to care team huddles, case conferences, and weekly clinical meetings.

- May facilitate psychoeducational groups and classes, and refer patients to appropriate community and county mental health resources.

- Assist patients, families, and staff in navigating and understanding community resources, in the areas of child custody, restraining orders, conservatorship, advance directives, and consults with Compliance or Risk Management if needed.

- Maintain accurate, timely records within the Electronic Health Record in accordance with organizational policy.

- Attend relevant trainings and in-services, and participate in ongoing quality improvement initiatives.

- Bring urgent/critical issues to supervisor’s attention with a sense of urgency.

- Documents comprehensive and accurate progress notes in a timely manner within the patient’s healthcare record.

- Maintains compliance with all applicable county, state, and federal laws and regulations, funder and program requirements, including maintaining timely, accurate documentation in EPIC and Health Plan electronic systems.

- Develops and maintains working professional relationships with RFHN and community agencies.

- Perform basic administrative tasks related to the job; updating community resource lists, reports, and other routines as required.

- Support your team of providers.

- Other duties as assigned and requested

Qualifications

QUALIFICATIONS

- Master's degree in Social Work (MSW) from a CSWE-accredited program, but the program will consider a Bachelor’s of Social Work (BSW) with at least 5 years of relevant clinical experience.

- Bilingual proficiency in Spanish and English.

- Ability to exercise independent judgment and sound clinical decision-making.

- Quickly learns new concepts and adapts with minimal guidance.

- Demonstrate ability to establish rapport with patients efficiently and effectively.

- Strong verbal and written communication skills, delivered in a professional manner.

- Demonstrates sound judgment and effective escalation skills, including the ability to raise routine workplace concerns with their direct manager first.

- Demonstrated ability to work effectively across culturally and economically diverse populations.

- Ability to build and maintain collaborative relationships across a patient's full care team, as well as with external agencies and community members.

- Prior experience in integrated behavioral health or primary care settings strongly preferred.

- Training in motivational interviewing preferred.

- A consistent, service-oriented approach to patient and staff interactions.

- Proficient in data entry and computer software; experience with Epic software a plus.

- Works independently to assess and manage assigned patient needs, prioritize tasks, and make routine decisions within the scope of the role; recognizes when clinical input is needed and promptly consults the appropriate clinical provider in person, by phone, or through approved electronic communication.

- Able to travel to all clinic locations

- Able to function independently and consult with a clinical provider when necessary.

- Up to date with COVID-19 vaccines per current CDC guidelines strongly recommended.