We are recruiting for a mission-driven Social Work Coordinator to join our team!

We're with you for life’s journey. At Denver Health, purpose isn’t just something we believe in-it’s something we live every day, for life’s journey.

Our Values

Respect | Belonging | Accountability | Transparency

Department

ACS-CHS Grants Funded

Job Summary

Under general supervision, the Health PlanDenver Health Pediatrics at Denver Public Schools School-Based Health Center (SBHC) Social Work Care Coordinator (SWCC) is responsible for facilitating and coordinating the care delivered to an assigned group ofpatients members using multidisciplinary and member/family collaboration to ensure quality and cost effectivecost-effective outcomes are delivered within appropriate care coordination parameters. Coordination involves assessment of care needs, planning, support, and evaluation of member care and related outcomes. Activities to be performed are screening and assessment of medical, behavioral health and social determinants needs and gaps in care, collaboration with the Member to develop a care plan with SMART goals, scheduled outreach to support member in achieving their goals and supporting the Members patientspatients' self-efficacy to navigate systems. SWCC communicates closely with the Member's care team inclusive of: the Member, designated health representatives, primary care provider, behavioral health providers and other care coordinators involved with the Member's Patient's care. Encounters occur face to face, telephonically, and electronically with members patients in clinic and in other community-based settings. SBHCs. Position is an active contributor in the development of systems (e.g.e.g., work flowsworkflows, clinical pathways, assessments) to improve the care of assigned member patient populations. Helps ensure compliance with state, federal and third party payor requirements.

Essential Functions:

• Utilizes Care Coordination Processes: • Systematically collects focused data relating health needs and concerns of memberpatient, group, or population. • Establishes and maintains memberpatient-centered relationships. • Analyzes assessment data to determine opportunities for health promotion, health maintenance or health related problem needs and statements. • Identifies and executes evidence-based interventions to support the Memberpatient in achieving their health goals. • Identifies and works towards expected outcomes in a plan of care individualized for a specific memberpatient, group or population. • In collaboration with the patientMember, develops a care plan that identifies strategies and alternatives to attain expected outcomes. Utilizes competent, evidence based, telephone encounters and electronic communications according to regulatory requirements and standards, as well organizational policies and procedures. • Conducts systematic evaluation of outcomes of care coordination in relation to structures and processes prescribed by plandetermined by grant. • Documents in readable, understandable language according to professional, regulatory, and agency standards. • Documents and disseminates results of care to memberpatient, caregivers, and others involved in the care or situation, as appropriate, in accordance with contractual requirements, state and federal laws, regulatory requirements, and Denver Health policy. (35%)
• Provide Care Coordination Services: • Coordinates the delivery of care within the clinic setting, throughout the organization, and across health care settings. • Provides relevant information across the care system, within Denver Health and with other healthcare systems and payers when member care is transferred between and among different specialties and/or within one or more organizations. • Provides information to the health care team including the memberpatient, family, and caregiver regarding available resources and benefits for health care services that ensures member choice and safe, timely transition. • Serves as point of contact within and among healthcare services and organizations. • Coordinates community resources. • Assures designation of primary responsibility among team members for each aspect of care plan, avoiding duplication and fragmentation. • Facilitates continuity of care using the multidisciplinary collaboration, and coordination of all appropriate healthcare services and community resources across the care continuum. • Orients member/caregiverpatient to health care delivery system, services, access, and resources. (30%)
• Health Teaching and Promotion: • Identifies barriers to goals and strategies to address. • Provides personalized education for optimal wellness. • Encourages preventative care such as immunizations and cancer screening.Well Child Checks. • Promotes appropriate utilization of resources. • Assists and educates caregiver when member is unable to participate. • Incorporates therapeutic communication, health literacy, cultural, and linguistic needs and preference into education and goals. • Supports members patients and caregivers in developing skills for self-efficacy to promote, maintain, or restore health such as healthy lifestyle tips, risk-reducing behaviors, age and developmental needs, daily living activities, and preventative care. (20%)
• Care Coordination • Responsible for a defined caseload of Members enrolled in the DHMP Medicare Choice Dually-eligible Special Needs Program (DSNP) patients who are identified as having a medium or low risk acuity level using data from a variety of sources, including the Memberpatient, their caregivers, providers, administrative claims data, pharmacy data and other inputs. • The DSNP Model of Care is a well-defined model requiring a comprehensive health risk assessment (HRA), individualized care plan (ICP) and integrated care team (ICT) review of the ICP. This routine is completed at least annually and more frequently when the Member experiences a change in condition, as evidenced by hospitalization, movement to a residential place of care or other event. • Obtains Member patient consent to participate in the program as well as to share clinical information with the Member’s Patient’s care team. • Works collaboratively with the patientMember to set SMART (specific, measurable, attainable, realistic and time-limited) goals. and to graduate the Member to lower-intensity care programs and self-care within reasonable timeframes. • Works under the supervision and advice of the Supervisor who can provide insight into medical conditions, treatments, medications and answer medically-related questions as needed. (15%)

Education:

• High School Diploma or GED Required

Work Experience:

• 1-3 years One year of direct member care experience in acute, ambulatory care or community based care Required

Licenses:

Knowledge, Skills and Abilities:

• Bilingual in English/Spanish, preferred.
• Knowledge of emotional and social factors that impact patient’s health.
• Excellent interpersonal skills.
• Skilled in identifying problems/opportunities to improve care.
• Ability to help the patient and family to understand, accept, and follow medical recommendations.
• Ability to utilize resources, such as family or community agencies, to assist the patient to resume life in the community.
• Ability to collect key information from the patient, family, and the community, as part of the social work assessment.
• Ability to communicate to the appropriate staff, information about the patient.’s discharge plan.
• Experience with windows-based computer programs and ability to use computer for data analysis and data display, required.
• Experience with Medical Management platforms used to document care coordination services, preferred.

Shift

Days (United States of America)

Work Type

Regular

Salary

$23.30 - $32.62 / hr

Benefits

At Denver Health, we take care of the people who take care of our community. Our benefits are built to support your life, your family, and your future - with generous paid time off, fully paid parental leave, exceptional retirement contributions, comprehensive health coverage, and nationally recognized well-being programs. We invest in your growth through tuition assistance, career advancement pathways, and professional development - while also offering meaningful financial advantages through loan forgiveness eligibility and employer contributions. When you join Denver Health, you’re joining a mission-driven organization that invests in you.

Here is a small list of our benefit programs:

• Paid time off starting at 28 days per year, inclusive of vacation, personal/sick, and 7 Holidays
• 100% paid parental leave up to 6 weeks
• Immediate eligibility for retirement plans with employer contribution up to 9.5%
• Generous medical, dental, vision plans in addition to employer paid disability and life insurance.
• Comprehensive well-being programs including on-site employee fitness center located on Denver Health main campus and nationally recognized RESTORE Center
• Free RTD EcoPass (public transportation)
• Childcare discount programs & exclusive perks on large brands, travel, and more
• Tuition reimbursement & assistance
• Education, coaching, and professional development opportunities through the Workforce Development Center (WFDC) that support internal career growth and advancement pathways
• Professional clinical advancement program & shared governance
• Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program
• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer

About Denver Health

Denver Health is an integrated, high-quality academic healthcare system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver’s 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, the Public Health Institute at Denver Health, Denver Health Medical Plan and Denver Health Foundation.

As Colorado’s primary, and essential, safety-net healthcare system, Denver Health is a mission-driven organization that has provided millions in uncompensated care for the uninsured each year.

Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.

Denver Health is an equal opportunity employer (EOE). We value the unique ideas, talents and contributions reflective of the needs of our community. All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made. Applicants will be considered until the position is filled.

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