The Social Worker coordinates a comprehensive patient care plan with the Nashville Babies Strong team including the PI/Medical Coordinator, Program Manager, providers and staff. The Nashville Strong Babies Project is a comprehensive case management and care coordination approach for women and infants at greatest risk for experiencing a poor perinatal outcome.
• Provide patient assessment according to project protocol. Conduct home visit with participants. Help create each participant individual care plan. Schedule additional visits with high risk patients.
• Provides direct patient follow-up care in collaboration with the OB/GYN and Pediatric Providers.
• Provides adherence counseling; monitors patient adherence to program plans; follow-up on patient adherence to counseling based on identified need and acuity.
• Provides patient education in conjunction with OB/GYN and Pediatric Provider.
• Serves as a principal liaison between patients and medical providers; coordinates and follows clinic referrals, appointments and educational classes.
• Develop collaborative approach to service delivery through integration of activities and services across all programs and projects.
• Develop new resources and relationships with outside service providers.
• Work with the Program Manager and key staff to develop and conduct quality assurance processes for client/site records
• Performs other related duties as assigned.
• Knowledge of clinical psychology
• Knowledge to foster excellent patient relationships
• Ability to work independently, take initiative, prioritize duties and work closely with other programs/projects.
• Organized, detail-oriented and have the ability to handle a variety of tasks simultaneously with a problem-solving approach.
• Skills working effectively with clients from diverse backgrounds, with sensitivity provided to people from diverse communities.
• Literacy and experience with Microsoft Office programs.
• Excellent written, verbal and telephone skills.
• Sensitivity to patient needs and cultural competence
• Knowledge of the healthcare environment
• Strong interpersonal and communication skills and supervision skills and the ability to work effectively with a wide range of constituencies in a diverse community and within the program.
• Records maintenance skills.
• LCSW required