Social Worker Care at Home: Remote - South Carolina

Optum Home & Community Care, part of the Optum family of businesses, is creating something new in health care. We are uniting industry-leading solutions to build an integrated care model that holistically addresses an individual's physical, mental and social needs - helping patients access and navigate care anytime and anywhere. As a team member of our Optum Care at Home product, together with an interdisciplinary care team we help patients navigate the health care system and connect them to key support services. This preventive care can help patients stay well at home. This life-changing work adds a layer of support to improve access to care. We're connecting care to create a seamless health journey for patients across care settings. Join us to start Caring. Connecting. Growing together. The Optum Dual Special Needs Plan (DSNP) Care at Home program is a longitudinal, integrated care delivery program that coordinates the delivery and provision of clinical care of members in their place of residence. The DSNP program combines Optum trained clinicians providing intensive interventions customized to the needs of each individual, in collaboration with the Interdisciplinary Care Team (ICT), which includes the Optum clinician, the member's Primary Care Provider, other providers, and other professionals. Optum providers serve people in their own homes through annual evaluations, ongoing visits for higher risk members, care coordination during transitions from the hospital or nursing home and ongoing care management. Reporting to the Social Work Manager, the Medical Social Worker (SW) is an integral part of the ICT. The primary role of the SW is to assess the psychosocial needs of patients and families and provide solution-focused case management interventions to address barriers to care and adherence to the medical care plan. The SW is an active member of the ICT, collaborating with patients, caregivers, providers, and community resources to support person-centered care. Social work services are provided telephonically or via telemedicine, as determined by state regulations and/or market needs. Professionals in this role elicit input from the ICT based on initial and ongoing comprehensive assessments of the patient. In addition to the SW, the Care at Home ICT includes but is not limited to, physicians, nurse practitioners, physician assistants, nurse care managers, behavioral health clinicians, pharmacists, care coordinators, the patient and/or caregiver and family. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Conduct a comprehensive psychosocial assessment of the patients and/or families strengths and needs Utilize evidence-based screening tools to assess behavior health conditions including depression, anxiety and substance use disorder Develop person-centered care plan goals with the patients, families or caregivers Facilitate serious illness and advance care planning discussion with the patient and family Provide brief therapeutic interventions and solution focused case management to patient and family, utilizing motivational interviewing (MI) and other techniques to address care plan goals Promote patient and family self-management strategies to support self-efficacy and patient empowerment Provide tangible case management support to patients and/or families and facilitate referrals for clinically indicated services outside of Care at Home (CAH) (e.g., social services, caregiver support, specialty care) Facilitate communication and collaboration among patients, families, caregivers, and members of the interdisciplinary care team to support patient-centered care goals When clinically indicated, and in partnership with CAH provider, conduct joint visits to facilitate prognosis awareness and health literacy Maintain patient confidentiality and protect sensitive health information in accordance with organizational, regulatory, and