Job Details

Accountable for managing targeted patient populations in order to achieve efficient and effective care delivery. Includes coordinating, facilitating, monitoring and evaluating interventions to achieve desired outcomes. Functions as part of an interdisciplinary team to guide and track individuals across time and delivery sites. Provide social work services for targeted populations and serve as social work resource for department. Essential Functions. All team members are expected to be knowledgeable and compliant with Prisma Health's purpose: Inspire health. Serve with compassion. Be the difference. Assists in development of an initial Plan of Care that highlights actual and potential self-management improvement opportunities. Facilitates and monitors implementation of Plan of Care. Coordinates patient/family participation in Plan of Care and self-management. Coordinates patient education to achieve Plan of Care. Performs home visits as necessary to evaluate possible barriers to a...Management, Social Worker, Embedded, Worker, Healthcare, Health