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Social Worker, Community Care Team
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Full-time
- Works with CCT Director, CCT Medical Director to establish patient selection criteria/High Risk Registry
- In consort with the CCT Medical Director/Director, attending hospitalist, specialist, or primary care physician (PCP), evaluate the patient's care plan, and recommends appropriate, timely, and beneficial interventions which promote quality, appropriate and cost-effective health care outcomes.
- Participates with on-call and weekend coverage rotation with the CCT. Our team provides 24/7 coverage for the hospital and ambulatory clinics.
- Attend training and educational seminars as approved by the CCT Director that are geared toward improving patient education on chronic disease self-management and reducing preventable hospital readmissions.
- Actively participate and lead initiatives in any Payer Pay for Performance or Quality Improvement Plan as designated by the Sr Director of Population Health or the CCT Director.
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