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Community Social Worker - SWHR CIN - Fort Worth at Southwestern Health Resources CIN in Dallas, Texas

Posted in General Business 30+ days ago.

Type: Full-Time

Job Description:

Southwestern Health Resources seeks to hire a Community Social Worker to work full time in their SWHR Utilization Management Department. This position is a field base position.

*Please Note: Southwestern Health Resources Clinically Integrated Network (SWHR CIN) is an affiliated company of Texas Health Resources and UT Southwestern. If hired for this position, you will become a SWHR CIN employee rather than a Texas Health or UT Southwestern employee.*

The address is 8150 Brookriver Drive, Dallas, TX 75247.

Salary range is Minimum $20.34/hr. to Maximum $39.50/hr. - based on relevant experience

Work Schedule:

    • Full Time; 1 st Shift • Monday - Friday, 8:00 AM - 5:00 PM • Field based position : Requires travel around the DFW Metroplex; primarily NW Fort Worth, Lake Worth, Eagle Mountain, Azle and Saginaw

Job Description :

    • Assess the biopsychosocial status of identified patients in the home or other settings initiating appropriate community referrals in addition to providing supportive counseling services to patients, families, and caregivers. • Community referrals include, but not limited to, provision of nutrition, prescription assistance, transportation, housing and rent assistance, and custodial in-home care. • Community social worker in collaboration with patient's medical home physician and team will assist with direct skilled nursing placement, arranging home health, arranging provider home visits, and hospice. • Conduct home, primary care clinic, and skilled facility visits as necessary developing a written plan to provide information and direction to the other health team members. • Interview patients, their families, and other concerned parties to obtain information about personal, social, and environmental history. Evaluate social functioning, particularly as it relates to medical problems, initiation, and follow-up of referrals to other resources. • Facilitate and manage referrals accordingly to ensure continuity of services. • Provide patient and family counseling for adjustment issues, grief, and end of life issues. • Provide support to patients and their families when personal, social or environmental difficulties exist which predispose illness or interfere with obtaining maximum benefits from medical or mental health care. • Chronic disease self-management- Instructing on coping strategies including planning, behavior modeling, problem solving techniques, and decision making related to managing chronic diseases. • Assess when appropriate, a patient and/or family's financial situation taking into consideration the patient's diagnosis, prognosis and medical needs, and refer to an agency for financial assistance if indicated, interpret the medical situation to the referring agency and generally facilitate the process of referral ; advise, counsel, and when appropriate, instruct the patient and family in the patient's social needs; provide advanced care planning education, documents, and assistance with completion of directive to physicians, medical power of attorney, and out of hospital do no resuscitate. • Coordinate with the patient, physician, and pharmaceutical company to provide prescription assistance. • Provide social work services to Extensivist Physician panel as needed • Participate in medical home, staff conferences presenting case histories; confer with other members of the medical home team to develop comprehensive evaluations or plans providing maximum benefits for each patient. • Assist in interdisciplinary team meetings in meeting the psycho-social needs of patients to enable patient to utilize medical, mental health, and community services. Assist the primary care physician and other team members in understanding the significant social and emotional factors related to the patient's medical diagnosis. • Assist patients and their families, through individual or group conferences, to understand, accept, and follow services planned to improve and restore patients to optimum social, medical, and mental health. • Maintain familiarity with community resources and agencies for assigned zone, local, and nationally updating resources as necessary Maintain professional relationships with other agencies and acts as an affiliate with community agencies; participate in area/zone activities related to health and community services . • Assist in the planning and implementation of special seminars and forums as needed. • Observe, record, and report information on the patient's condition to the primary care physician or medical home team. Prepare and maintain a case record for each patient to describe the nature of social problems and services suggested or provided, responsible for follow-up and case documentation. • Perform other duties as assigned.

The ideal candidate will possess the following qualifications:

    • Bachelor's Degree in Social Work required • Master's Degree in Social Work highly preferred • 3 years working in a community/outpatient setting, in the geriatric field working in a direct service capacity, or social work experience in an inpatient setting required. • Health Care setting preferred, previous experience in home care setting a plus.

Licenses and Certifications:

    • LBSW - Licensed Bachelor Social Worker upon hire required • LMSW - License Master Social Worker upon hire highly preferred • DL - Drivers License upon hire required


    • Must have knowledge and demonstrate knowledge of community information and resources for referrals • Chronic disease management of diverse patient populations and/or experience in health coaching preferred • Must work well with geriatric population with the ability to counsel and provide crisis intervene with patients and families, particularly regarding end of life issues • Excellent time management skills with ability to prioritize tasks effectively