Palliative Care Social Work Case Manager

• Telephonic and video visits with patients and caregivers
• Establish trust and build strong relationships with our patients
• Interdisciplinary collaboration with teammates (including clinicians, nurses, and care coordinators) to ensure cohesive, patient-centered care for high-needs patients
• Conduct Social Work interventions to maximize the effectiveness of the program
• Conduct psychosocial assessments and create personalized care plans tailored to members’ needs

Provide emotional and caregiver support

• Assist in navigating complex family/support issues
• Complete goals of care conversations and advanced care planning
• Conduct long term care planning and placements
• Place/follow through on behavioral health referrals
• Investigate concerns for patient abuse or neglect
• Know how to balance multiple competing priorities from complex patients
• Work with family members/caregivers to help them in understanding the member’s needs and how they can be supportive
• Manage or lead conversations with patients, caregivers, and family regarding goals of care, and social drivers of advanced care planning
• Facilitate and participate in family meetings and joint visits
• Participate in team huddles, panel reviews, interdisciplinary team rounds, and program/role growth and development
• Build relationships and coordinate with key local market and internal stakeholders
• Document all clinical interactions in the electronic health record

Attributes to success

• Ability to walk alongside those with terminal illness and to gentle the sacred transition from life to death
• You meet patients and families where they are, hold them with compassion, and are able to release yourself from the outcome
• You love helping others improve their health and navigate a complex healthcare system with compassion, empathy, and warmth
• You’re a caring problem solver who can break down barriers

You connect with people quickly

You follow up relentlessly

• A deep caring to make a change in the healthcare experience: you love to serve and make a difference
• The ability to adjust your tone and approach to different people
• You can articulate and break down complex information
• Being present, reliable and timely - for our members, for your team
• The ability to work in a startup environment: which means moving quickly and being transparent in your work, what’s going well, what’s not
• You enjoy a fast-paced, high-energy, organization; Agility and collaboration are key as we will change and improve quickly
• You are comfortable engaging and learning new technologies including electronic health records, operating systems and programs (Google Office, Slack). You thrive on knowing your work can help make these technologies better for you and your patients.
• You learn from every experience and are not afraid to fail - that's how you're wired
• Finally and most importantly, you have a passion for making healthcare better for patients at end-of-life, solving complex problems, and supporting the delivery of healthcare that we would want for our own family members