Licensed clinical social worker - summit medical group | Tuscaloosa, AL

with the potential for high risk complications and coordinate the appropriate treatment in conjunction with the patient and care coordination team. Coordinate with institutional facilities as necessary to facilitate access to physical health and/or behavioral health services needed by the SMG patient and to help ensure the proper management of the patient's acute and/or chronic physical health or behavioral health conditions backss clinical information to develop an individualized transition plan, if appropriate, that will address all the services necessary to safely transition the patient to the community, including, but not limited to, patient needs related to housing, transportation, availability

of caregivers, and other transition needs and supports.

Act as an advocate for an individual's health care needs by identifying and communicating opportunities for care intervention, including identifying and addressing gaps in care.

Also by identifying and communicating any barriers to a safe transition and strategies to overcome those barriers. Utilize criteria for authorizing appropriate home and community based services, obtain authorization for those services, if needed, and confirm those services are being provided and that patient's needs are being met. Monitor and ensure that provision of covered physical health, behavioral health, and/or home and community based services

are provided as a cost-effective alternative. Management of critical transitions, such as hospital discharge planning.

Develop and implement targeted strategies to improve health, functional, or quality of life outcomes, such as disease management or shop management.Maintain appropriate and ongoing communications and collaborations with patient's, their authorized representatives, physicians and health team members, and payer representatives. Provide assistance in resolving concerns about service delivery or providers. Coordinate with SMG patient's primary care provider, specialists, and other providers and care programs to ensure comprehensive, holistic, person-centered approach to care.

Provide patients with education about the ability to use an advance directive. Routinely backss and monitor patient's status, needs, and progress; if progress is static or regressive, determine reason and proactively encourage appropriate adjustments in their plan of care, providers and/or services to promote better outcomes. Report quantifiable impact, quality of care, and/or quality of life improvements as measured against the care coordination goals Establish working relations with referral sources, community resources, and care providers. Actively participates in site-level Quality Improvement Activities.

Each employee will contribute to the continual evaluation site performance as well as the implementation and measurement of improvement activities that increase the quality of care provided to patients. Qualifications Education: • Master's Degree of Social Work and L. C. S. W. required; Minimum of 3 years varied clinical background required; • Care management experience preferred. Experience: • Prefer 3 - 5 years' experience in healthcare setting• Three to five years of experience in care management, disease management, population health management, or other related health care environments.

• Prefer experience with chronic disease management/education• Must be PC literate with basic knowledge of Windows & Microsoft. Overview About Summit Medical Group Summit Medical Group is East Tennessee's largest primary care organization with more than 400 providers at 87 practice locations in 18 counties. Summit also consists of four diagnostic centers, mobile diagnostic services, eight physical therapy centers, four express clinics, central laboratory, and sleep services center. Summit provides healthcare services to more than 370,000 patients, averaging over one million encounters annually.

For more information, visit In addition to our commitment to the health of our community, our organization is also committed to the health of our employees through our employee Wellness Program. Employees receive a discounted monthly insurance premium if they actively participate in the wellness program. Furthermore, Summit Medical Group hires only non-tobacco users. Pre-employment drug testing will include testing for nicotine, and only candidates who pass the drug test will be considered eligible for employment. For more details: jobs-search.

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