Palliative Care Social Worker Navigator

Institution name:

North Texas Specialty Physicians – Silverback Care Management


Fort Worth, TX, United States, 76104

Salary Range (Annual Salary)

$48000 - $60000


This position is responsible for coordination/navigation of patient care for the outpatient palliative care population. This position will also be responsible for community case management through Silverback. Leads collaborative practice with the physician and other members of the health care team to meet patient- specific and age-related patient needs, linking cost resource management and quality to patient care. This position requires a high level of interpersonal skills. Navigation activities include leading care coordination and transition/discharge planning across the care continuum. Navigation also includes 1) Leading and facilitating the coordination of patient’s palliative care team and family/caregivers; 2) conducting advance care planning conversations and documentation; 3) Coordination and patient visits with other community providers (e.g. SNF, Hospice, Home Care); 4) Coordination of care for patients; 5)Developing the palliative care team processes for the program. Completes established competencies for the position within designated time periods. Other related job duties as assigned.

General Functions:
• Leads and facilitates coordination of patient’s palliative care team and family/caregivers.
• Leads development of palliative care service delivery processes and program.
• Leads patient care conferences with other providers.
• Conducts comprehensive assessments of the patient’s health and psychosocial needs, and develops a case management plan in collaboration with the client and client’s support system.
• Acts on physician recommendations for follow up care after palliative care clinic visit by communicating with patient, family, and other caregivers in the community.
• Demonstrates proficiency of clinical case review and appropriate levels of care across the care continuum for managing complex cases.
• Demonstrates proficiency with caseload assignment and ability to manage complex cases effectively.
• Identifies health disparities and removes barriers.
• Demonstrates the ability to evaluate utilization/resource/clinical care management data to identify trends, develop action plans, and program modification for change.
• Demonstrates a solid understanding of managed care trends, Medicare and Medicaid regulations, reimbursement and the effect on utilization and outcomes of the different methods of reimbursement.
• Educates the patient, family or caregivers, and members of the health care delivery team about treatment options, community resources, insurance benefits, and/or psychosocial concerns so that timely decisions can be made.
• Engages with patient to promote self- management.
• Ensures patient has appropriate advance care planning conversations and documentation
• Demonstrates the ability to develop departmental interfaces with internal and external customers to provide exemplary service and achieve goals
• Demonstrates participation in multidisciplinary team rounds in designated facilities to address utilization/resources and progression of care issues. Assists in developing and implementing an improvement plan to address issues
• Implements goals and objectives that support overall strategic plans of the organization
• Supports and works within annual department operating and capital budgets
• Supports the mission statement, policies and procedures of the organization
• Achieves ongoing compliance with all regulatory agencies
• Serves as a resource to employees and customers as demonstrated by visibility and
• Demonstrates leadership to others on the care management team
• Utilizes resources efficiently and effectively
• Maintains a safe environment
• Participates in Performance Improvement activities

• Bachelor’s degree from a social work program accredited by the Council on Social Work Education (CSWE). Master’s degree is preferred.

• Three (3) years of complex case management/navigation experience in an acute or post-acute provider or health plan.
• Working knowledge and ability to apply professional standards of practice in work environment.
• Working knowledge of computers and basic software applications used in job functions such as word processing, databases, spreadsheets, etc.

• Four to Five (4-5) years’ complex case management/navigation experience in hospice or long term care setting.
• Palliative care experience.
• Experience with geriatric population.
• Strong analytical and organizational skills.
• Working knowledge and ability to apply professional standards of practice in work environment.
• Knowledge of specific regulatory and managed care requirements.

• Licensed Bachelor of Social Work (LBSW), Licensed Master of Social Work (LMSW).
• In good standing with the Texas State Board of Social Work Examiners.
• A valid Texas Driver’s license and proof of valid liability insurance is required.

• Certified Case Manager (CCM) or Certified Social Work Case Manager (C-SWCM)

The above job description is not intended to be an exhaustive list of all responsibilities, duties, and skills required of the job. Management retains the right to add or to change the duties of the positions at any time with or without notice.

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