• Job Description

  Req#: 21596

  Department Overview

  OHSU is Oregon’s only public academic health center. We are a system of hospitals and clinics across Oregon and southwest Washington. We are an institution of higher learning, with schools of medicine, nursing, pharmacy, dentistry and public health – and with a network of campuses and partners throughout Oregon. We are a national research hub, with thousands of scientists developing lifesaving therapies and deeper understanding. We are a statewide economic engine and Portland’s largest employer. And as a public organization, we provide services for the most vulnerable Oregonians, and outreach to improve health in communities across the state.

  OHSU’s Care Management Department includes inpatient RN case management (adult, pediatrics, ED, mission control), RN BPCIA care managers, RNs in Care Transitions for the Underserved, post-acute, and assigned clinic RN care managers. While this Clinical Outreach Social Worker (COSW) position is within OHSU's Care Management department, this work requires unique skill set, flexibility and vast network of community partners to be able to effectively offer care. Assessments and services are offered in the ED, hospital, on the streets and in homeless camps, in patient homes, outpatient clinics, and other community settings. The COSW coordinates treatment efforts with other OHSU departments, partners, community partners and affiliates to advocate for client needs.

  The Clinical Outreach Social Worker (COSW) uses advanced clinical and/or healthcare operational subject matter expertise combined with systems and workflow knowledge to manage and assist in compassionate interventions to patients with complex psychosocial needs who discharge from OHSU Emergency Department and hospital. The COSW prioritizes clients with limited connections to outpatient services and frequent ED encounters. This population is growing in numbers, cost and complexity.

  Schedule: Flexible to needs of the business

  Preferred Schedule: Monday-Friday either four 10 hour shifts, or five 8 hour shifts

  This position is a flexible work position, which allows some remote work. The Social Worker generally is expected to be in person at least half of their work time, depending on the expectations of their specific position. The social worker should have a private space at home, dedicated to work, and no Protected Health Information should be printed. Social Workers are expected to see patients in person, when at all possible, which may require coming to the hospital at short notice on a remote day.

  Wage Range: $86,367.06 - $130,782.86 per year

  Function/Duties of Position

  $5,000 hiring bonus

  Intense Clinical Management

  Care Planning:

  • Assesses patients for psychosocial and transitional care needs and participates in developing patient-centered care plan.
  • Assists patient in identifying goals and recognizing associated behavioral modifications.
  • Acts as a liaison between patient and medical team when necessary and contributes clinical expertise to care plan, offers recommendations for diagnosis and treatment of mental health and addresses addictions issues when appropriate.
  • Facilitates linkage to clinics that best meet patient’s needs, and may arrange appointments, complete intake paperwork, plan transportation options, accompany client to appointments, and support the patient and clinic staff during initial transition period.
  • Provide high level clinical care planning to outpatient community providers, and support both the patient, prescribers, and the clinics while during this engagement period.
  • Assists patients in securing services to stabilize housing, obtain employment, access financial entitlements, treat addictions issues, and meet basic physical needs.
  • Content experts in identifying, care planning and intervening to address the numerous disparities the target population faces with regards to Social Determinants of Health.

  Coordination of care:

  • Facilitates cross-site communication between hospitals, clinics, and other community agencies.
  • If patient returns to ED/hospital, SW serves as a source of knowledge about patient’s goals, care trajectory, post-discharge needs, and barriers to outpatient care.
  • Composes and/or updates EDIE care guidelines to increase cross-system knowledge of care plan.
  • Provide other professionals with clinical background and recommendations on how to proceed with a highly complex and traumatized patient.

  Clinical services:

  • Offers clinical expertise to medical providers when relevant to drive effective diagnosis and treatment of mental health, substance use disorders, and to provide basic medical care to those experiencing homelessness.
  • Provides intensive outreach and engagement to access needed community services, providing education, counseling and motivational interviewing to enhance outcomes of recommended supports and interventions.
  • Use of therapeutic techniques, by creating mutually agreed upon goals, help the patient enhance physical, psychological and social functioning.
  • Practice interpersonal communication and system navigation skills alongside the patient.
  • Maintains state of the art knowledge of social services in the Tri-County area, including but not limited to shelter access, medical insurance, housing resources, MAT programs, and specific mental health treatment options.
  • Providing higher level teaching and mentorship on assessment and resources availability to hospital and community based social workers, nurses and physicians.

  Interface with insurance companies:

  • Must be highly knowledgeable of insurance coverage needs, requirements and processes, including: facilitating prior authorizations and be able to provide clinical justification and documentation when needed.
  • Submits complex care need requests for flex funding with clinical rationale.
  • Required to be able to navigate both the physical and behavioral-based insurance care needs.

  Data

  Quality improvement:

  • Maintain independent preparation of data, design and collection in collaborating with teammates on an ongoing basis to evaluate program effectiveness.
  • Solicits feedback from patients, interdisciplinary colleagues, and community partners to improve service delivery.
  • Work to add to the overall knowledge of the hospital staff to have the needed expertise to engage in care to a population that can face barriers in engagement and have resounding care needs.
  • Facilitates patient movement through the OHSU system, coordinates and facilitates quality related throughput, and balances need for services that are both financially viable and effective.

  Educational Training

  Education:

  • Maintains active clinical licensure and obtains required CEUs.
  • Participates in continuing education as a learner but also accepts opportunities to provide cross-disciplinary education via rounds, committees, conferences, and presentations when relevant opportunities arise
  • Provide psychoeducation to patients and/or their families, and providers that we directly work with.
  • Offer coaching, mentoring, training to medical, nursing and social worker students, as well as to fellow colleagues and peers at OHSU. This training is focused on resources availability but also in clinical delivery of care with population with complex care needs.

  Required Qualifications

  • Master's in Social Work
  • LCSW, in the State of Oregon
  • Valid OR/WA driver’s license with an acceptable driving history and access to a car on a daily basis for home visits
  • 3+ years of professional experience diagnosing, treating and advocating for adults with mental illness and co-occurring substance abuse disorders in medical or community mental health settings. Experience working within the Portland social service community and extensive knowledge of community resources
  • Experience working with an under-served adult population experiencing mental illness, substance abuse and chronic illness
  • Able to do all functions of the job with or without acommodation

  Preferred Qualifications

  • 5+ years of professional experience diagnosing, treating and advocating for adults with mental illness and co-occurring substance abuse disorders in medical or community mental health settings
  • Experience working within the Portland social service community and extensive knowledge of community resources
  • Experience conducting home visits and street outreach
  • Familiar with street safety assessment and crisis interventions and response
  • Post Graduate training and certification applicable to the job

  Additional Details

  Benefits:

  • Two raises per year – One at anniversary date and one across the board annual increase
  • Healthcare Options - Covered 100% for full-time employees and 88% for dependents, and $25K of term life insurance provided at no cost to the employee
  • Two separate above market pension plans to choose from
  • Vacation- up to 200 hours per year depending on length of service
  • Sick Leave- up to 96 hours per year
  • 8 paid holidays per year
  • Substantial Tri-met and C-Tran discounts
  • Additional Programs including: Tuition Reimbursement and Employee Assistance Program (EAP)

  All are welcome

  Oregon Health & Science University values a diverse and culturally competent workforce. We are proud of our commitment to being an equal opportunity, affirmative action organization that does not discriminate against applicants on the basis of any protected class status, including disability status and protected veteran status. Individuals with diverse backgrounds and those who promote diversity and a culture of inclusion are encouraged to apply. To request reasonable accommodation contact the Affirmative Action and Equal Opportunity Department at 503-494-5148 or aaeo@ohsu.edu.

• About the company

  Oregon Health & Science University is a public university in Oregon with a main campus, including two hospitals, in Portland, Oregon.

Notice