Community Accountable Care Social Work Navigator (Exempt)

Facility

Cape Fear Valley Medical Center

Location

Fayetteville, North Carolina

Department

Managed Care Planning

Job Family

Professional

Work Shift

Days (United States of America)

Summary

Provides clinical case management services for high-risk patients. Ensures clients have adequate treatment plans and access to the care they need through biopsychosocial assessment, diagnoses, treatment, and prevention services.

Major Job Functions

The following is a summary of the major essential functions of this job.  The incumbent may perform other duties, both major and minor, that are not mentioned below.  In addition, specific functions may change from time to time:

• Conduct face-to-face assessments of patient/family needs by coordinating input from all healthcare providers and formulate a treatment plan for continuity of care

• Work with an integrated health care team to diagnose and create a treatment plan for patients with multiple co-morbidities including behavioral and mental health concerns

• Assess and plan for continuity of patient care following hospital admission, discharge, and ED visits to ensure proper information and resources referrals, client education, and consultations directly related to their treatment plan

• Completion of in-home visits for clients with mental, emotional, addictive, behavioral, or developmental disorders and conditions to execute their treatment plans and identify social barriers that may impact their ability to care for themselves and improve their overall health

• Conduct biopsychosocial assessments of individuals and/or families prior to creation and implementation of treatment plan

• Builds and advocates for community engagement

• Provides various healthcare needs in a community outreach clinic setting

• Support patient self-management of disease and behavioral modification through techniques such as motivational interviewing, health coaching, and solution-focused therapy

• Completion of comprehensive assessments to identify solutions for chronic disease management, psychosocial needs and socioeconomic vulnerabilities

• Other duties as assigned

Minimum Qualifications

The following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job:

Education and Formal Training: 

• Master’s Degree in Social Work or related field required

• Current North Carolina Licensed Clinical Social Worker-Associate (LCSWA) required OR

• LCSWA must be obtained within 60 days of employment and must pass current North Carolina state licensing exam within 24 months of obtaining provisional license

Work Experience: 

• 1-year Case Management and/ or geriatric experience preferred

Knowledge, Skills, and Abilities Required: 

• Excellent written and verbal communication skills

• Ability to work independently, setting priorities to coordinate care plan efficiently as well as be able to work effectively in a team environment

• Ability to effectively communicate with physicians, patients, and their families and all levels of staff within the organization as well as with outside resources

• Effective behavioral and educational strategies including, but not limited to motivational interviewing, teach-back method and self-management support

• Ability to recognize the role of cultural, social, economic and behavioral factors and respond to the diverse needs that result from these differences

• Ability to adapt quickly to changing patient needs and applicable organizational and federal regulations

Physical Requirements: 

• Hearing, speaking, and visual acuity are required

Required Licenses and Certifications

Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity