The Population Health Social Worker is responsible for providing case management services to high risk patients populations including adults, pediatrics, elderly, and patients experiencing a transition of care. The Population Health Social Worker will work with a multi-disciplinary team and community agencies to facilitate and implement a comprehensive care plan to manage the health conditions, utilization of resources and encourage self-management in high risk patient populations. The Population Health Social Worker reports to the Director of Population Health.
Principal Duties and Responsibilities*
1) Case Management a. Provide case management for high risk patient populations. b. Create and implement care plans based on comprehensive, culturally competent assessment with interdisciplinary input that promote patient well-being and ensure a continuum of care. c. Provide ongoing assessment and modify care plans accordingly. d. Advocate for the needs and interests of the patient related to healthcare. e. Maintain records or documentation of social work services which reflect the patient’s pertinent information for assessment and treatment and social work involvement and outcomes, in accordance with administrative regulations and policies.
2) Measure and Improve Patient Outcomes a. Re-evaluate care management interventions and strategies and work to revise and improve care management efforts and interventions to improve outcomes of patients. b. Work with the Population Health Manager to set specific quality goals related to each care team’s patient population. c. Track and gather data related to patient care plans and goals.
3) Leadership and Training a. Facilitate collaboration among care team members to address the patient’s psycho social needs to better provide efficient, appropriate, and beneficial health care services to patients. b. Participate in internal and external meetings and committees as necessary and participate as an LCHC representative on various care management committees.
• Must be familiar with laws and mandates related to confidentiality, including HIPAA regulations. • Sensitive to the diversity in cultural groups and ability to work in a multi-cultural setting. • Demonstrates excellent communication skills and able to communicate clearly to patients, staff, and community agencies • Demonstrated problem-solving skills • Strong ability to multi-task and work well in a fast-paced, team environment • Demonstrated effective interpersonal relationship and customer service skills • Strong organizational and time management skills • Flexibility to work at different LCHC sites and on weekends/evenings, if necessary • Embraces and personifies the mission of Lawndale Christian Health Center, by performing work in a whole person way, providing for the physical, emotional and spiritual needs of patients
Required Knowledge, Experience, or Licensure/Registration
• Masters Degree in Social Work from an accredited university • Licensed in the State of Illinois preferred • Experience with case management of patients of various risk groups and chronically ill patient groups preferred • Bilingual in English and Spanish preferred
Internal Number: 8725883020
About Lawndale Christian Health Center
The mission of Lawndale Christian Health Center is to show and share the love of Jesus by promoting wellness and providing quality, affordable healthcare for Lawndale and the neighboring communities.
Our values are an extension of the Christian Community Development philosophy, embodied by the "3 R's": Relocation, Reconciliation, and Redistribution. Lawndale Christian Health Center was founded by Lawndale Community Church in 1984.
Lawndale Christian Health Center is recognized by the National Committee for Quality Assurance (NCQA) as a Patient Centered Medical Home (PCMH). PCMH is a model of health care that strengthens the relationship between providers and patients through long term care from one care team at one location led by a physician. As a PCMH, Lawndale Christian Health Center’s goal is to provide personalized and coordinated care that is high quality, affordable, and effective.
PCMH services provided by LCHC include same day, evening hours, and weekend appointments, preventive care, school physicals, an online patient portal, and self-care management.
Through our mission, LCHC is working to improve the health of the more than 60,000 patients who have chosen u...s as their medical home, as well as the health of our surrounding community.
For the 20-30% of our patients who have no insurance, LCHC is the place where quality health care is accessible. For community residents who are seeking jobs, LCHC is a place to secure employment. For students, LCHC is a place to receive training. For our peers, LCHC is a place to find ideas about providing healthcare for an underserved community. And for each of our patients and friends, we hope that LCHC is a place where they experience the love of Jesus Christ.
Lawndale Christian Health Center is accredited by the Joint Commission on Accreditation of Health Care Organizations (JCAHO), and is recognized as a Federally Qualified Heath Center (FQHC) by the U.S. Department of Health and Human Services' Bureau of Primary Health Care.