Job Description

Overview:

Responsible for a panel of patients and, in collaboration with other members of a multidisciplinary primary care team, helps patients meet their preventive, chronic, and acute care needs.

The LMSW will engage patients and encourage them to take an active role in their health by

providing them with the tools necessary to make healthy lifestyle choices and adopt lifelong healthy behaviors. This individual’s primary responsibilities center around establishing trusting, supportive, collaborative relationships with patients and their families.

Day to day Responsibilities:

• Function as a patient advocate by attending patient appointments when requested/needed two.
• Document relevant information about the patient’s health and healthcare experience and perform health risk and social needs assessments.
• Collaborate with a multidisciplinary team to care for a population of patients and monitor and track whether patients are up to date on preventive measures.
• Provide patient education on acute and chronic disease management.
• Provide guidance to patients and families.
• Establish healing relationships with patients and families.
• Learn to employ confidence-promoting techniques in patient communication and develop patient self-efficacy to better manage health.
• Communicate with patients in-person and by phone, video conference, and text messaging.
• Collaborate with other members of the multidisciplinary care team including but not limited to the manager, Transitions of Care manager, Medicaid case managers, and medical assistants.

Qualifications:

• Bilingual/Bicultural (English and Spanish)
• Experience in a customer service environment
• Some clinical experience is a plus, such as LMSW or CHW-Instructor.
• Experience working with geriatric population.

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