Care Coordinator/Social Worker

Explore opportunities with Optum, in strategic partnership with ProHealth Care. ProHealth Care is proud to be a leader in health care services, serving Waukesha County and the surrounding areas for more than a century. Explore opportunities across the full spectrum of care as you help us improve the well-being of the community with your skills, compassion and innovation. Be part of a collaborative environment that strives for excellence, nurtures respect and ensures high-quality care delivery to our patients. Join us in making an impact as an Optum Team Member supporting Pro Health Care and discover the meaning behind Caring. Connecting. Growing together.

The Social Worker is responsible to act as a liaison and assists in coordinating resources for the care of health plan members with multiple co-morbidities and/or psychosocial needs. The primary scope is to provide counseling and assistance to patients and their families as requested with personal, financial, ethical, and environmental difficulties that predispose patients to illness. The Social Worker acts as an advocate for members and their families, linking them to community resources and financial assistance programs for continued growth toward a maximum level of independence. The Social Worker will interact and collaborate with the interdisciplinary care team, which includes physicians, nurses, case managers, pharmacists, laboratory technologists, other social workers, dietitians, and other educators.

The Social Worker (SW) is responsible and accountable for coordination of patient services through an interdisciplinary process, which provides clinical and psychosocial approach through continuum of care. Discharge planning will begin at the time of (or prior to) admission, and reassessed ongoing throughout the course of hospitalization. Provides direct social work/case management services to patients and/or families and hospital staff to ensure needed assessment intervention, support, and referral. Coordinates services with other members of the health care team community wide. Respond to information and referral needs of the community. The foundation of the SW role includes crisis intervention, comprehensive understanding of mental health diagnosis, brief counseling, working collaboratively with community vendors, identifying resource needs, arrange and facilitate meetings with the health care team as needed, problem solving and promoting patient wellness.

Schedule: Monday - Friday, 8:00AM - 4:30PM / 12:00PM - 8:30PM

Primary Responsibilities:

• Coordinates patient care processes to achieve desired quality outcomes and identifies / controls appropriate resource utilization
• Provides skilled interventions for: patient/family support and/or resolution of patient/family crises; facilitating problem-solving and decision-making; advocacy and facilitation necessitated by life-changing events (new diagnosis, abuse, loss of independence, bereavement); and mediation of risk factors and various psychosocial issues
• Assesses need for post-hospital services and community resources at the time of discharge
• Develop plans of care and management plans for patients who frequent the Emergency Department in partnership with patient physician, ED Provider, and community resources
• Support patients, caregivers and/or families with psychosocial or behavioral needs
• Educate patient/family on options and choices available within the appropriate level of care
• Reports child and adult abuse and neglect to community agencies as mandated by law
• Assesses patients who may have experienced violence and make appropriate reports and referrals
• Educates and collaborates with Care Team on care planning and discharge resources
• Involves staff at the next level of care when appropriate to promote continuity of care
• Interfaces with Department Leaders, Risk Management and patient representatives to identify potential QA or risk issues
• Participates in departmental quality improvement projects
• Initiates all necessary paperwork for all reports, plans of care, referrals, and community resources
• Must be able to functionally coordinate and discharge plans for all age groups, including the unborn child through geriatric age groups
• Is familiar with and expected to comply with all regulatory requirements, including CMS and Joint Commission Standards

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in.