High Risk Care Team Social Worker - Remote

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The Iora Health model of care changes everything. Will it change you?

Iora Health has one mission: to restore humanity to health care. Our aim is simple: to deliver robust, dynamic primary care that transforms our patients’ lives. 

We are seeking a full-time High Risk Social Worker to join our Iora+ High Risk Care team in the Surprise or Sun City, AZ area. This Social Worker will serve as a key member of the Iora+ High Risk Care team, playing a critical role in managing the care needs of our high risk/high need patients primarily in the home and/or virtually. The High Risk Social Worker will perform intakes with the High Risk Nurse Practitioner together, managing patient case loads, and connect patients as appropriate to essential resources that are critical to their care.

Iora has a network of primary care practices where we take the time to know our patients as true individuals, and proactively provide the care, support, and inspiration they need to live their best life. Our practices offer smaller panel sizes, no billing or coding, and the opportunity to lead systemic change in health care delivery while working with a true team. We are a fast-paced, fresh-thinking, high-growth company building a better model of health care delivery.

Position Highlights:

  • Serve as a key member of the High Risk Care Team, in partnership with an NP, RN, and support staff, as well as practice-based care teams, to follow a team-identified panel of patients until their needs have stabilized. Care interventions will primarily be delivered in the home and/or via phone.
  • Support high risk, high need patients and their families to address barriers to their overall care and management of chronic conditions until they are stable and able to return to the general primary care population
  • Work with patients and caregivers to understand barriers to accessing appropriate care and assist in developing a care plan for chronic condition management and overall care
  • Support care team in executing care plans once patients move out of the high risk care team panel
  • Perform Advance Care Planning, resolving family conflict, connect to community based resources, understanding of how to navigate state, federal, and VA Benefits
  • Meet patients where they are at - both physically and mentally, to support care. Provide support in the home, in facilities, or via phone based on patient need. 
  • Facilitate conversations around goals of care, patient values, conflict resolution, and Advance Care Planning
  • Work with external partners such as discharge planners, UM staff, insurance case managers, state agencies such as Medicaid and SNF case managers to facilitate care 
  • Refer patients to appropriate community agencies and resources. Support care team in navigating community referrals. 

Qualifications:

  • Must have a Master's degree in Social Work and relevant experience 
  • Experience in a medical, hospital, hospice, or PACE setting strongly preferred
  • Experience with team based care, excellent collaboration skills 
  • Experience with an integrated team setting in a geri or home based setting
  • Excellent working knowledge of community resources, assessing social determinants of health, medical terminology, and working with a geriatric population
  • Exceptional capacity to multitask
  • Self-directed
  • Comfort with ambiguity
  • Strong communication and teaching skills. 
  • Understanding of Mac iOS, Google suite.
  • Daily access to a vehicle with valid driver’s license
  • Flexibility and willingness to travel around the Surprise/Sun City area of the West Valley

Iora Health is an equal opportunity employer, and we encourage qualified applicants of every background, ability, and life experience to contact us about appropriate employment opportunities.

In order to ensure the health and safety of Iora patients and Iora team members, Iora requires all employees to be fully vaccinated for COVID-19, except where a medical or religious accommodation applies.