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at Landmark Health
- Clinical Delivery Field
- Regular Full-Time
- Job ID
Do you want to make a difference in healthcare?
Landmark Health was created to transform how healthcare is delivered to the most medically vulnerable members in our community. Our medical group provides home-based medical care to chronically ill patients, many of whom are frail, elderly and ill-equipped to navigate our overwhelming healthcare system.
Because many of our patients are frail and elderly, we deliver care primarily in the comfort of their home. Our Program is also offered to eligible patients at no incremental financial cost to them. We are not a fee-for-service practice; we benefit economically only if we deliver high-quality patient outcomes and satisfaction. As a result, our clinical teams can spend quality-time caring for a smaller number of patients, giving all patients the space, respect, compassion and care they deserve.
Our model is finding success throughout the country; we are now the nation’s largest risk-based, in-home medical group.
At Landmark, our interdisciplinary teams collaboratively manage our complex patient panels. These teams are led by Physicians, Nurse Practitioners, and Physician Assistants, with supporting care provided by RN Nurse Care Managers, Social Workers, Pharmacists, Behavioral Health and other employed team members.
The primary role of the Social Worker is to assess the psychosocial needs of members and provide risk-focused care coordination to address issues that impede their ability to adhere to their medical care plan. The SW is an active member of the Interdisciplinary care team (IDT).
The Social Worker is responsible for:
- assessing members’ psychosocial concerns and the impact on their current medical status;
- developing collaborative care plan goals with the member, IDT members and/or their family/ caregiver;
- connecting member and/ or their family/ caregiver to appropriate community resources and supports;
- providing short-term, risk-focused case management;
- utilizing motivational interviewing (MI) and other psychotherapeutic techniques to elicit behavior change;
- promoting patient self-management strategies;
- enhancing connectivity between patients and members of the interdisciplinary team; and
- navigating community resources and develop partnerships to improve access to care and ease of systems navigation.
- Master’s Degree (MSW) in Social Work
- Meet all state certification and licensing requirements, licensure in NC preferred
- Minimum of three (3) years of social work experience (internship not included)
- Minimum of two (2) years of social work experience in a healthcare setting
- Experience in delivering home-care or field case management is preferred
- Excellent communication skills and knowledge of accessing community resources
- Possession of a valid state driver’s license and access to an automobile