DUTIES: 80% Care Coordination: - Provide overall coordination for mental health and social services for patients of SUNY Downstate - Primary Care Ambulatory Care Department. - Collaborate in a team-based care model with all members of the patient care team including PCPs, nursing, behavioral health and support staff. - Participate in at least weekly caseload review with supervisor. - Maintain a tracking system for active and inactive patients to reflect status and disposition. - Communicate with all parties required to ensure appropriate referrals are made and loops are closed, including patients, families and caregivers, SUNY Downstate divisions, care coordinators and other relevant staff at external agencies, and insurance companies. Document in EMR all interventions and interactions. - Interact and communicate with inpatient discharge planning staff, social work and care management to manage care transitions for high-risk outpatients. Perform duties of the Collaborative Care program Care Manager, including: - Enrolling eligible and consenting patients. - Utilizing the CMTS registry tool to manage and track all enrolled patients while ensuring that all encounters and necessary information are documented in the EMR. - Utilize online community resource directories such as NOWPOW, HITE SITE or other available directories as well as online patient lookup tools, e.g., Healthix and NYS OMH PSYCKES system. - Participate in workgroups and meetings related to care transformation initiatives such as DSRIP, Patient Centered Medical Home and management of high-risk patients. 10% Teaching Responsibilities - Educate residents on the availability of community resources. - Teach residents how to interact with Social Workers as part of an interdisciplinary team. Educate residents on the many aspects of social workers' abilities and responsibilities in the different care settings in which they work. - In conjunction with the Medical Director and Residency Program Director, develop periodic group visits for patients with chronic medical conditions that serve educational and support functions for patients as well as model the group visit structure for medical learners. (DUTIES AND RESPONSIBILITIES ARE NOT LIMITED TO THE ABOVE POSITION DESCRIPTION) QUALIFICATIONS: - Minimumof Masters of Social Work and a New York State License required. 3-5 years of work experience including teaching experience preferred. Experience working in team-based model in primary care preferred. Additional Info: *Please ensure you include the 5-digit Line Number and Job Title in the subject line and body of your email submission.Closing Date: Open Until Filled STATE UNIVERSITY OF NEW YORK IS AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER
Internal Number: 52787
About SUNY Downstate Medical Center
SUNY Downstate's College of Medicine, Health Related Professions, Nursing and its School of Graduate Studies offer students a broad professional education that will prepare them for practice or careers in any location and community. This education provides exceptional opportunities for those students with a commitment to promoting health in urban communities and addressing the complex challenges of investigating and preventing diseases that confront clinicians, educators, and researchers in such an environment. This special aspect of Downstate's unique mission is reflected in the students it attracts and selects, the vast majority of whom are drawn from the New York City Metropolitan area. Many of these students are members of minority and cultural groups underrepresented in the health professions, and/or come from families of first-generation immigrants or from economically disadvantaged backgrounds.