Chronic Care Social Worker - Evernorth Health Services - Remote

Must be located in the greater Philadelphia area.

Evernorth Home Based Care, a division of Evernorth Health Services, is the premier home-based healthcare solution for patients and families facing chronic, complex and life-threatening illness. We are an innovative, multi-specialty practice experiencing tremendous growth nationwide. We offer patients and families a complete population health model, focusing our practice in caring for patients across the continuum of complex and serious illness.

Utilizing telephonic and virtual outreach methods, the Evernorth Home Social Worker is responsible for coordinating with patients and key clinical partners to aid in the delivery of cost-effective, high quality health care. The social worker will support programs aimed at meeting the complex needs of our clients including advanced care planning, psychosocial support, and complex care coordination. Social workers will attend in-person trainings / meetings monthly or on an as-needed basis to support program goals.

Key Responsibilities

Identifies and addresses social determinants of health and other barriers that impede the patient’s ability to adhere to their medical care plan

Provides assessment, planning, coordination, monitoring, and evaluation of care plan to ensure each receives the services and support required to meet psychosocial and health care needs

Engages patient and family in care coordination, goals of care conversations and advance care planning.

Provides brief psychosocial support to patients and family members navigating chronic illness and / or change in functional status

Engages Interdisciplinary clinical care team to achieve identified patient outcomes

Minimum Qualifications

Current Licensure as a LCSW in the state of PA

Master's Degree

Expectation to sit / apply for cross-licensure in additional states within 90-120 days of hire date. (Licensure costs to be covered upon hire.)

Three (3) to five (5) years recent clinical experience

Preferred Qualifications (Experience)

Clinical experience in one of the following selected fields of social work :

Hospital / Community Coordination of Care / Population Health

Skilled Nursing / Rehabilitation / Long Term Care

Managed Care / Geriatric Social Work

Home Health / Hospice / Palliative Care

Job Related Skills :

Excellent time management, organizational, research, analytical, negotiation, communication (oral and written) and interpersonal skills

Strong skills in the following areas : teamwork, conflict management, assessment of complex issues, ability to recommend changes and resolve problems through effective decision making

Knowledge of managed care and utilization review requirements and procedures

Demonstrated sensitivity to culturally diverse situations, participants and customers

Ability to work within changing business environment and balance business needs with patient advocacy

Demonstrated ability to coach and educate patients and other staff

Strong personal computer skills, EMR experience, MS word, Excel, Outlook experience, and Internet research desired