Job #: 2796
Title: Social Worker
The primary goal of maternal health quality care Social Worker will be to improve the population health of high risk obstetrical patients and reduce the incidence of severe maternal morbidity (SMM) and maternal mortality (MM). The High Risk Maternal Medical Home (HRMMH) is aimed at improving the quality of high risk maternity care, improving maternal and infant outcomes and reducing Severe Maternal Mortality (SMM) and Maternal Morbidity (MM).
Candidates will provide information to patients on appropriate use of Obstetrical ambulatory visits, connect them to local resources in their communities, information specific to their Maternal Care provider, navigating the system, referrals to public charge, behavioral health support, etc.
Responsibilities will include but not limited to:
Assisting with patient outreach, care coordination services, and navigation of the health care system.
Utilizing population management data and resources to identify at risk patients and facilitate appropriate support and resources.
Providing patient outreach, implementing appropriate evidence based guidelines, monitoring care plan compliance and removing barriers to success.
Facilitating patient engagement with their medical home, assisting with access to and navigation of the health care system.
Documenting interventions in the patient’s electronic medical record.
Participating in care team meetings, performance improvement and patient satisfaction initiatives.
Reporting issues and system barriers to efficient and effective care management.
Maintaining compliance with organizational policies, procedures and evidence based guidelines.
Electronic documentation in the electronic medical record to further inform care improvements and management of the program.
Evaluate the behavioral health needs of clients and providing behavioral health counseling support to the hospital-based program
Provide intake and as well as administrative support for the high risk obstetric medical home. Maternal Care Assistant Director, Social Work will also accept requests for services, as patients are referred from high risk obstetric practices
Ensure data collection from each program he/she supervises, as well as compile reports as needed from the program
Attend regular meetings of program leadership and ensure contact with the program director and manager.
NYS – Licensed Medical Social Work or Licensed Clinical Social Work. Three years work experience working with ambulatory obstetrics patients ( pre-natal or post partum).
The candidate must be able to travel to any of 11 facilities for work or meetings.