The Population Health Social Care Supervisor will:  

• This position will have oversight and project management responsibilities for community-based initiatives. 

• Experience working with underserved and diverse populations in community settings required. 

• Develops and monitors Social Care team goals; provides ongoing feedback and coaching; conducts annual performance reviews; routinely evaluates staff’s skills and technical comprehension 

• Contributes to the growth and success of their team and CHW program and its goals.  

• Active participation in CHW forums and community-based initiatives. 

• Analyzes processes and procedures to develop innovative approaches to challenges or issues. 

• Attend and actively participate in all project related trainings and project meetings. 

• Strive for high customer satisfaction by providing prompt, solution-focused support to team, co-workers, patients, and community partners. 

• Ensures an atmosphere of open communication, teamwork, and empowerment to make informed decisions. 

• Collaborates with Senior Manager of Population Health Transformation in analyzing reviews, metric data, and chart audits and uses that information to identify opportunities for improvement. 

• Collaborates with Senior Manager of Population Health Transformation on overall budget for Care Management. 

• Oversees Social Care Team position control and hiring of new staff. 

• Contributes to the clinical, quality and financial outcomes of the Population Health Department. 

• Familiarity with value-based payment models and supports payor related value-based care programs. 

• Performs all other related duties as assigned by Senior Manager of Population Health Transformation. 

• Demonstrates a measurable, organized, enthusiastic and outcomes-oriented approach. 

The Social Care Team is responsible for supporting and coaching at-risk patients to manage their own health and assisting them in navigating the health care and social service systems.  

• Reliable and accessible transportation along with current insurance coverage is required. 

• Complete all required documentation and data tracking in a detailed and timely manner. 

• Complete all telephone and face-to-face contacts with patients in a timely and professional manner.  

• Complete enrollment forms and other needed documentation and documents in approved format in a timely manner.  

• Assist patients in the community through home visits, attending medical appointments, and accessing other community-based resources.  

• Assist patients in the community through home visits, attending medical appointments, and accessing other community-based resources.  

• Must have the ability to relate to diverse groups of people and people on all levels.  

• Provide support and education to patients to assist them in adhering to medical recommendations and taking medications as prescribed.  

• Assist patients in scheduling medical and social service appointments and attending appointments as needed or requested.  

• Assist patient in securing transportation to medical and social service appointments.  

• Provide assistance with medical and behavioral health referrals to ensure client access and follow-through.  

• Assist patients in obtaining necessary medications through patient assistance programs and other reduced cost programs.  

• Complete client-centered treatment goals in collaboration with patients and review progress in meeting goals routinely and at identified 60-day check-in times.  

• Provide regular and timely updates to medical providers, referral sources, and assigned clinics on patients' progress to meet treatment goals and to trouble shoot any problems or concerns.  

• Review referral forms, needs assessments, or Electronic Medical Record data and determine appropriateness of referrals. For patients not appropriate for projects, provide active referrals to other community resources.  

• Assist clients in accessing and understanding necessary health and wellness information provided by their medical provider and clinic.  

• Ensure client’s access to interpreters and translators for medical and social service appointments.