This position is in part a grant funded position and is contingent on the renewed funding at the end of each award period.

JOB SUMMARY:

This position is primarily responsible for providing direct support and communication to the site medical team as well as a wide range of social work and medical case management services to CBHS patients and families, with the goal of addressing social determinants of health that directly impact access to and engagement in medical care and treatment. Activities include working with an interdisciplinary team to support, guide, and address treatment, education, adherence and psychosocial needs; directly facilitating specialty medical care referrals, and external medical stakeholder activities/communication as needed. This position will also serve as the coordinator for specialty care internal referrals as well as coordinate student interns for their site.

MAJOR DUTIES AND RESPONSIBILITIES:

Planning and Organizing

* With the support of program leadership, the SWCM coordinator is responsible for direct and effective communication with all medical staff at their site location of CBHC, assuring that requests regarding care from medical providers are implemented and monitored in accordance to organizational and regulatory standards of care.

* Participates in the development and implementation of psychosocial interventions which aligns with CBHC strategies and medical/grant deliverables.

* Plans, coordinates, and participates in case conferences with multi-disciplinary teams regarding challenges with specific client issues.

* Organizes and tracks all internal referrals from their site location of CBHC.

* Serves as the JHH TAP Program Navigator for their site location.

* Will serve as the BCCDT contact for their site location and provide updates regarding internal referrals made.

* Communicates directly with Field Placement liaison regarding student placements from affiliate schools and assists with Field Instructor coordination.

Checking, Examining, and Recording

* Maintains assigned project reports, documents, and data, including but not limited to Tableau reports on internal referrals.

* Provides audits of follow up regarding internal referrals and will report findings directly to the Director of SWOD.

* Collects necessary documentation for specialty care referrals including but not limited to JHH TAP.

Communication

* Participates in provider meetings at site location as well as daily morning huddle to provide updates as well as provide discourse regarding SWOD's interventions.

* Will spend, at minimum, one day per week in the medical pods to facilitate communication and familiarity with site medical team.

* Collaborates directly with medical providers regarding coordination of care.

* Proactively develops and maintains positive working relationships and collaborates with medical teams across sites as well as external medical partner entities.

* Responsible for direct communication with the JHH TAP Program Coordinator as well as organizing all associated paperwork.

Teamwork

* Orients staff and students as assigned by Director. Oversees the orientation of new Social Work hires by establishing the plan and monitoring progress in conjunction with Director.

* Monitors and arranges for adequate staffing daily to ensure appropriate Social Work coverage for site. Monitors daily workflow issues and communicates to Director, as necessary.

* Responsible for site scheduling including keeping track of outages, late arrivals, and early dismissals on weekly schedule.

Compliance, Policy, and Procedure

* Document all services as directed by CBHC policy, State requirements, and professional standards.

* Adheres to departmental and policy and procedures.

* Demonstrates appropriate use of billing, grant or orders coding for all EHR documentation.

Patient Care

* Referrals patients to on- and off-site community resources.

* Provides clinic and triage coverage as assigned

* Maintains an established caseload of patient and monitors for medical adherences as well as psychosocial barriers to care.

SKILLS AND ABILITIES:

* Excellent verbal and written communication skills

* Ability to work with diverse populations

* Knowledge of community resources

* Knowledge of Ryan White service deliverables

* Excellent attention to detail and organizational skills

* Demonstrate ability to communicate with providers of many disciplines with ease and confidence

* Must be able to adapt to changes within the organization and in the field of Health Care

EDUCATION AND/OR EXPERIENCE:

* Required: Master's Degree in Social Work

* Active Maryland State Social Work License (LGSW, LCSW, LCSW-C)

* MHBE Insurance Assister/Counselor Certification within one year of hire

* Four years of related experience in a health care setting and Community, case management, and/or outreach experience.

WORKING CONDITIONS/PHYSICAL DEMANDS:

Work is typically performed in an office environment.