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Full/Part Time: Full Time
Location/Affiliates: Mount Sinai Medical Center (Manhattan)
Department: 186 - Social Services
Requisition Number: 13-1574512
The Mount Sinai Medical Center has been selected by the Centers for Medicare and Medicaid Services (CMS) to serve as an Accountable Care Organization (ACO), which is part of the Affordable Care Act. The ACO, called Mount Sinai Care, comprises several outpatient primary care practices on the Manhattan campus (FPA Primary Care Associates, Internal Medicine Associates, Coffey Geriatrics and Mount Sinai Visiting Doctors) and in Queens, Yonkers and Long Island. This new position will be based in Internal Medicine Associates. The patients served in the ACO are Medicare Fee-for-Service and Medicare/Medicaid patients. There are currently 22,000 patients assigned to the ACO from CMS across all practices with the number expected to grow to 25,000 in the near future.
The primary goal of the ACO is to improve appropriate utilization of medical services across the health care continuum, improve quality of care by focusing on preventive care and decrease costs (e.g. reduction in unnecessary tests/labs being ordered, preventing Emergency Department visits and hospital admissions/readmissions). At regular reporting periods, the ACO must show a minimum of 2.5% total savings in its total Medicare expenditures and achieve certain scores in 33 metrics related to patient safety, patient satisfaction and health outcomes.
The role of the ACO social worker is to serve as a member of the interdisciplinary care team and to work closely with this team and the high risk patients (designated by assigned risk scores) to conduct care coordination to assist in the achievement of the ACO goals. The ACO social worker will conduct biopsychosocial assessments of the patient and family caregiver as needed, identify barriers to seeking appropriate medical care and work with the team and patient/family caregiver to develop a care plan
to overcome these barriers and increase compliance (with appointments, medication regimen, etc.). The ACO social worker will communicate with external organizations in the community to facilitate adherence to the care plan (e.g. transportation, legal, housing). The ACO Social Worker will run, filter and analyze population management reports in Epic and review CMS claims data to identify preventive care/screening and disease management care gaps, high emergency department, inpatient and specialty utilization and share this information with the care team to develop care coordination interventions. The ACO social worker is responsible for educating patients/family caregivers on how to navigate the health system and empowering them to use MyChart so they can access their most recent health information regularly. The ACO social worker with the care team is responsible for referring high risk patients with continued health management issues to the high risk interdisciplinary team which will discuss the case and explore other options. For common patients, the ACO social worker communicates with care coordinators in other MSMC programs to ensure collaborative and seamless work.
New York State LMSW or LCSW required
Exceptional skills in engaging patients and families and in assessment and coordination of resources within families and hospital and community networks for effective management of patient care.
Exceptional organizational, collaborative and psychosocial assessment and intervention skills.
Interest in being part of an innovative initiative to improve the quality of care by addressing barriers to primary and specialist care, preventable Emergency Department visits and hospital admissions/readmissions.
Hospital experience and experience with geriatric patients preferred.
Proficiency in MS Office: Word, Excel, Outlook. Ability to learn hospital ambulatory scheduling system, electronic medical record and specific care coordination applications.
Mount Sinai Medical Center is an equal opportunity/affirmative action employer. We recognize the power and importance of a diverse employee population and strongly encourage applicants with various experiences and backgrounds. Mount Sinai Medical Center--An EEO/AA-D/V Employer.