The Population Health Licensed Social Worker works in collaboration with a multidisciplinary team of clinicians to provide high quality, outcome-based, patient-centered care and address the social determinants of health to support safe transitions of care across the continuum for patients of CentraState Medical Center and the Atlantic Health System.
- Support high-cost/high-risk patients to address barriers to care and navigation challenges across the care continuum by screening for and prioritizing the patient’s health and SDOH needs, addressing gaps in internal and community-based resources, and creating sustainable connections to medical homes and social care supports to improve the patient experience, achieve better health outcomes, decrease avoidable cost and utilization, and increase the utilization of preventative care and healthy behaviors to improve health.
- Provide psychosocial assessment, sustainable care transitions, and structured support to help address social and economic barriers to positive health outcomes and empower patients to set and achieve their individualized health goals. Apply best practice interventions based upon care standards and referral and linkage to services to ensure behavioral and psychosocial needs are addressed, including but not limited to: social needs, financial stressors, difficulty coping, behavioral health concerns or substance misuse, abuse and neglect, interpersonal violence, homelessness, functional decline, frequent ED visits or hospitalization, transportation to follow up appointments, medication assistance, etc.
- Maintain best practices, process systems, and key performance metrics to provide effective outcome-based, patient-centered care with a focus on culturally-sensitive and inclusive interventions, equitable access to care, and reduction in health disparities. Conduct psychosocial assessment, social determinants of health screening and referral, and develop a plan of care in alignment with individual needs, values, and goals of the patient. Provide individual telephonic/virtual support and guidance to patients, using appropriate techniques and evidence-based theories to guide patients toward healthy coping, self-management, and overall wellness. Maintain accurate and timely referral response, assessment, intervention, and documentation, according to department workflow and policy.
- Ensure ongoing collaboration and communication with the larger interdisciplinary clinical team, providers, discharge planners, health equity coordinators and care team members to comprehensively address evolving psychosocial needs, medical needs, and plan of care. Maintain a current knowledge base of community agencies and key contacts using a social care network closed-loop referral platform and EMR to assist with patient advocacy, navigation, and engagement with sustainable medical, social, insurance and benefit systems
- Regularly attend and actively participate in assigned intradisciplinary and interdisciplinary forums, administrative meetings, staff meetings, supervisory sessions, and in-service training. Provide consultative support for department community health workers through education, training and one to one case oversight. Annually participate in a minimum of 3 educational programs on topics relevant to practice area.
- Other tasks as required by manager, director, or leadership.
- Master’s Social Work Required
- Minimum of two years’ experience in medical social work strongly preferred
- Licensed Social Worker / New Jersey Required
- Strong professional, organizational, and interpersonal skills to effectively relate with all members of the healthcare team
Exceptional organizational and time management skills with the ability to multi-task, problem-solve, and balance and deliver results in a program with multiple projects, programs, and priorities
Strong clinical, interpersonal, and analytical skills with clear verbal, telephonic and written communication
Ability to function within an interdisciplinary team and develop and enhance collaborations with local community agencies and organizations
Ability to navigate EMR and databases with demonstrated ability, including EMR documentation standards, Microsoft Office suite and metrics/outcome reporting
Strong interpersonal and communication skills, problem solving, ability to work with diverse populations, compassionate service delivery
Bilingual a plus
CentraState Healthcare System, a partner of Atlantic Health System, is a fully accredited, not-for-profit, community-based health system that provides comprehensive health services in the central New Jersey region. In addition to offering a full range of leading-edge diagnostic and treatment options, CentraState serves as a valuable health partner focused on the latest ways to prevent disease, promote healthy behaviors, and help people of all ages live life well. Based in Freehold, CentraState is comprised of a 284-bed acute-care hospital, a vibrant health and wellness campus, three award-winning senior living communities, a charitable foundation, and convenient satellite health pavilions offering primary care and specialty physician practices, along with access to outpatient services, such as lab and physical therapy. The system also offers a family medicine residency and geriatric fellowship training program in affiliation with Rutgers Robert Wood Johnson Medical School. Among its many honors and accreditations, CentraState is one of less than two percent of hospitals nationwide to earn Magnet® designation for nursing excellence four times and was designated a Great Place to Work-Certified™ Company by Great Place to Work® for the second consecutive year.
When you bring your talent to CentraState, you are joining a trailblazing healthcare facility, committed to providing high-quality, patient-focused care. Join us in making incredible strides in health care, and making a difference in our community. We believe in enriching the lives of our employees through work/life balance initiatives, tuition assistance, career advancement opportunities and much more.
Find out why our employees love their jobs and being part of the CentraState family!
What We Offer:
- Highly competitive compensation
- Excellent benefits package and rewards program
- 403(b) retirement plan with company match
- 401(a) retirement plan with employer contribution
- Life Insurance
- Tuition Reimbursement Program
- Profit Sharing Program
- Growth Opportunity and Workforce Development Initiatives
- Continuing Education / Onsite Training
- A warm, welcoming company culture based upon mutual respect and a collaborative goal of providing excellent patient care
- Concierge Services with Work & Family Benefits
- Magnet recognized healthcare facility
At CentraState Healthcare System, we welcome and promote the diversity of our employee family! Each unique person contributes to the overall success of this organization. Our inclusive culture fosters an environment of professionalism and respect for personal differences.
CentraState Healthcare System, is an equal employment opportunity employer and federal contractor or subcontractor and, therefore, abides by applicable laws to protect applicants and employees from discrimination in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, pregnancy, gender identity or expression, sexual or affectional orientation, national origin or nationality, citizenship status, disability, age, genetics, protected veteran status, ancestry, marital status.