Social Worker, Neighborhood Care (Cambria Heights - In Person)

Summary of Position

Provide behavioral health services for the chronically ill or at-risk population in a community-based setting with an overall objective to help member's live fuller and more meaningful lives. Manage members with behavioral health, substance abuse, and/or psychosocial conditions/issues. Consult with all members of the team on behavioral health, substance abuse and/or psychosocial issues. Facilitate member adoption of strategies to promote physician-recommended behavior change. Help members improve health outcomes with feedback from the medical team and EmblemHealth's Case Management team as needed.

Principal Accountabilities

• Perform member outreach - virtually, telephonically and in-person, individual needs assessment, education on early warning signs of disease prevention, and identifying members in potential need of care.
• Provide support services as well as social services supports from other organizations (community based and otherwise).
• Provide assessment, planning, implementation, coordination, monitoring, and evaluation to ensure member receives care management services and support required to meet psychosocial, educational and health care needs.
• Assist members with the coordination of services from various settings as appropriate including supporting discharge from acute setting to home and acute setting to alternate settings.
• Provide care coordination throughout the continuum of care by including the member, member's family, and providers in the process.
• Support activities of other Neighborhood Care team members.
• Participate in all other projects relating to community clinical programming as identified by Regional Manager, AVP in Neighborhood Care and Medical Management Leaders.
• Participate as part of the Quality and Customer Experience team by providing feedback and ideas to continually improve clinical metrics and other customer experience.
• Other duties/responsibilities as directed, assigned, or required.