Do you want to make a difference in healthcare?
Landmark Health was created to transform how healthcare is delivered to the most medically vulnerable members in our community. Our medical group provides home-based medical care to chronically ill patients, many of whom are frail, elderly and ill-equipped to navigate our overwhelming healthcare system.
Because many of our patients are frail and elderly, we deliver care primarily in the comfort of their home. Our Program is also offered to eligible patients at no incremental financial cost to them. We are not a fee-for-service practice; we benefit economically only if we deliver high-quality patient outcomes and satisfaction. As a result, our clinical teams can spend quality-time caring for a smaller number of patients, giving all patients the space, respect, compassion and care they deserve.
Our model is finding success throughout the country; we are now the nation’s largest risk-based, in-home medical group, with operations in six markets and four states across the country.
At Landmark, our interdisciplinary teams collaboratively manage our complex patient panels. These teams are led by Physicians, Nurse Practitioners, and Physician Assistants, with supporting care provided by RN Nurse Care Managers, Social Workers, Pharmacists, Behavioral Health and other employed team members.
The primary role of the Social Worker is to assess the psychosocial needs of members and provide risk-focused care coordination to address issues that impede their ability to adhere to their medical care plan. The SW is an active member of the Interdisciplinary care team (IDT).
The Social Worker is responsible for:
Assessing members’ psychosocial concerns and the impact on their current medical status
Developing collaborative care plan goals with the member, IDT members and/or their family/ caregiver
Connecting member and/ or their family/ caregiver to appropriate community resources and supports
Providing short-term, risk-focused case management
Utilizing motivational interviewing (MI) and other psychotherapeutic techniques to elicit behavior change
Promoting patient self-management strategies
Enhancing connectivity between patients and members of the interdisciplinary team
Navigating community resources and develop partnerships to improve access to care and ease of systems navigation
3 years of social work experience (internship not included)
At least 2 years of social work experience in a healthcare setting
Experience in delivering home-care or field case management is preferred
Excellent communication skills and knowledge of accessing community resources
Master’s Degree (MSW) in Social Work
Possession of a valid state driver’s license and access to an automobile
Job ID: 2018-2251
External Company URL: landmarkhealth.org
Street: 3455 One Mill Run