Chronic Care Social Worker - Evernorth Health Services - Remote

About the position

Evernorth Home Based Care, a division of Evernorth Health Services, is seeking a Chronic Care Social Worker to join our innovative, multi-specialty practice that is experiencing tremendous growth nationwide. This position is fully remote, but candidates must be located in the greater Philadelphia area. As the premier home-based healthcare solution for patients and families facing chronic, complex, and life-threatening illnesses, we focus on delivering a complete population health model that addresses the needs of patients across the continuum of complex and serious illness. In this role, the Chronic Care Social Worker will utilize telephonic and virtual outreach methods to coordinate care with patients and key clinical partners, ensuring the delivery of cost-effective, high-quality healthcare. The social worker will support programs designed to meet the complex needs of our clients, which include advanced care planning, psychosocial support, and complex care coordination. Monthly in-person trainings and meetings may be required to support program goals, allowing for continuous professional development and collaboration with the interdisciplinary clinical care team. The ideal candidate will be responsible for identifying and addressing social determinants of health and other barriers that may impede a patient's ability to adhere to their medical care plan. This includes providing comprehensive assessments, planning, coordination, monitoring, and evaluation of care plans to ensure that each patient receives the necessary services and support to meet their psychosocial and healthcare needs. Engaging patients and their families in care coordination, goals of care conversations, and advance care planning will be crucial to achieving positive patient outcomes.

Responsibilities
? Identifies and addresses social determinants of health and other barriers that impede the patient's ability to adhere to their medical care plan.
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? Provides assessment, planning, coordination, monitoring, and evaluation of care plan to ensure each receives the services and support required to meet psychosocial and health care needs.
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? Engages patient and family in care coordination, goals of care conversations and advance care planning.
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? Provides brief psychosocial support to patients and family members navigating chronic illness and/or change in functional status.
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? Engages Interdisciplinary clinical care team to achieve identified patient outcomes.

Requirements
? Current Licensure as a LCSW in the state of PA
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? Master's Degree
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? Expectation to sit/apply for cross-licensure in additional states within 90-120 days of hire date (Licensure costs to be covered upon hire)
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? Three (3) to five (5) years recent clinical experience

Nice-to-haves
? Clinical experience in Hospital/Community Coordination of Care/Population Health
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? Clinical experience in Skilled Nursing/Rehabilitation/Long Term Care
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? Clinical experience in Managed Care/Geriatric Social Work
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? Clinical experience in Home Health/Hospice/Palliative Care

Benefits
? Flexible work environment
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? Professional development opportunities
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? Supportive team culture
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? Health and wellness programs

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