Care Collaboration Supervisor

BASIC FUNCTION:

Provides oversight, direction, support and supervision to the Care Collaboration Unit (CCU) staff. Conduct comprehensive intake, assessments, and reassessments when a referral or request from interdisciplinary team internal/external, family member or care takers. Must be able to provide counseling if appropriate or refer to Behavioral Health Providers as needed. Provide guidance to staff in determining goals, treatment plans, and directives to ensure quality patient/client services. When needed, provide crisis intervention to patient/client and families with appropriate linkage to services. Facilitate conversations between patient/client and families with their primary care, additional healthcare providers, or other support services, by empowering them to discuss unmet medical needs or problems that may affect health and wellness. The employee will work with other Seneca Nation Health System (SNHS) departments as well as other Seneca Nation departments.

GENERAL RESPONSIBILITIES:

1. Provides holistic care to patients by completing a psychosocial assessment of needs incorporating spirituality.
2. Assists patients with goals and objectives, encouraging ownership of their health and wellness.
3. Establishes goals and assigns to supporting staff within the unit or refer to other units to address needs; this will include working through noted barriers for the individual which may affect health and wellness.
4. Assists patients, families, and CCU staff with navigating complex medical systems, providing referrals to the unit team to assist when needed in scheduling appointments, requesting referrals and arranging transportation.
5. Collaborates with hospitals, nursing homes social workers, and CCU staff to ensure that patients are provided with a safe discharge and continuity of care.
6. Attends care plan meetings with outside and internal resources to ensure that patients and family members’ goals are discussed and met; this includes potential discharges from nursing home and assisted living and will act as a liaison to these departments, families, and internal staff particularly when cases are complex.
7. Works collaboratively with Adult Protective Services for adults on Seneca Nation Territory when reports of abuse are received through county agencies and will be the liaison with this entity as well as legal to ensure that appropriate referrals are made for the individual.
8. Supports the CCU staff by assisting with medical advocacy to complex patients with comorbidities, including organ transplants, mental health and substance abuse issues.
9. Provides support to patients and families needed to cope with chronic illnesses. Provides education and assists with referrals for other services.
10. Collaborates with other professionals to evaluate patient’s medical or physical condition and to assess patient needs.
11. Educates patients on chronic and terminal illnesses discussing options for end of life care. Discusses end of life choices, decision-making, and resources including hospice care, living wills/advance directives/healthcare proxy/MOLST and grief counseling.
12. Records medical social work activities and prepares reports as required, reviews CCU staff notes as needed.
13. Leads interdisciplinary treatment team to facilitate effective treatment/care planning, including supervision.
14. Assists in development and implementation of in-service training and other educational programs intended to maintain optimal effectiveness among SNHS staff.
15. Coordinates and/or participates in community planning for essential services to meet social, emotional, and health needs of the population served by the SNHS, as well as combating social problems.
16. Collaborates with medical providers, BHU staff, and other agencies within and outside of SNHS.
17. Develops and implements department policy and procedures in accordance with SNHS, Seneca Nation, Federal and State regulations.
18. Participates in the Human Resources process with employee relations, orientation and training, hiring, evaluations, and termination of staff in accordance to established policies and procedures.
19. Ensures confidentiality of records according to the provisions of the Privacy Act of 1974 and HIPAA.
20. Regular travel to both territories is necessary to ensure effective performance of all job duties and responsibilities.
21. Upholds and promotes the value and integrity of the Seneca Nation Health System’s mission statement. Will promote SNHS in a positive manner.
22. Provides care through a trauma-informed lens by incorporating key principles of both physical and psychological environment safety, trustworthiness and transparency, collaboration of decision-making during treatment plan developments, empowerment of patients by recognizing and building upon individual strengths, as well as recognizing and respecting the diversity of cultural backgrounds and sensitivity.
23. Attends all mandatory staff meetings, trainings and in-services.
24. Follows all department, SNHS, and Seneca Nation policies.

KNOWLEDGE, SKILLS, & ABILITIES:

• Excellent oral and written communications skills including public speaking.
• Highly organized, with the ability to develop organizational tools and track data.
• Excellent computer skills including word processing, email, internet, spreadsheet and database usage.

QUALIFICATIONS:

• Master’s Degree from an accredited school of social work or related field is required.
• NYS current and unrestricted license as a LMSW or LCSW required.
• 5 years’ experience in developing and implementing health promotion, disease prevention programs required.
• 3-years supervisory experience is required.
• Valid NYS driver’s license required.
• Experience in a large hospital, academic medical center, outpatient health care setting, or Indian Health Service (IHS)/tribal health, preferred.

Salary : $35