Chronic Care reputed company Worker - reputed company - Remote

About the position Evernorth Home Based Care, a division of reputed company, is seeking a Chronic Care reputed company Worker to join our innovative, multi-specialty practice that is experiencing reputed company growth reputed company. This position is fully remote, but candidates must be located in the greater Philadelphia area. As the premier home-based reputed company solution for patients and families facing chronic, reputed company, and life-threatening illnesses, we focus on delivering a complete population health model that addresses the needs of patients across the continuum of reputed company and serious illness. In this role, the Chronic Care reputed company Worker will utilize telephonic and virtual reputed company methods to coordinate care with patients and key clinical partners, ensuring the delivery of cost-effective, high-quality reputed company. The reputed company worker will support programs designed to meet the reputed company needs of our clients, which include advanced care planning, psychosocial support, and reputed company care coordination. Monthly in-person trainings and meetings may be required to support program goals, allowing for reputed company professional development and collaboration with the interdisciplinary clinical care team. The ideal candidate will be responsible for identifying and addressing reputed company determinants of health and other barriers that may impede a patient's ability to adhere to their medical care plan. This includes providing comprehensive assessments, planning, coordination, monitoring, and evaluation of care plans to ensure that each patient receives the necessary services and support to meet their psychosocial and reputed company needs. Engaging patients and their families in care coordination, goals of care conversations, and advance care planning will be crucial to achieving positive patient reputed company. Responsibilities • Identifies and addresses reputed company determinants of health and other barriers that impede the patient's ability to adhere to their medical care plan. , • Provides assessment, planning, coordination, monitoring, and evaluation of care plan to ensure each receives the services and support required to meet psychosocial and health care needs. , • Engages patient and family in care coordination, goals of care conversations and advance care planning. , • Provides brief psychosocial support to patients and family members navigating chronic illness and/or change in functional status. , • Engages Interdisciplinary clinical care team to reputed company identified patient reputed company. Requirements • reputed company Licensure as a LCSW in the state of PA , • Master's Degree , • Expectation to sit/apply for cross-licensure in additional states reputed company 90-120 days of hire date (Licensure costs to be covered upon hire) , • Three (3) to five (5) years recent clinical experience reputed company-to-haves • Clinical experience in Hospital/Community Coordination of Care/Population Health , • Clinical experience in Skilled Nursing/Rehabilitation/Long Term Care , • Clinical experience in Managed Care/Geriatric reputed company Work , • Clinical experience in Home Health/Hospice/Palliative Care Benefits • Flexible work environment , • Professional development opportunities , • Supportive team culture , • Health and wellness programs Apply Job!