Inspired by faith. Driven by innovation. Powered by humankindness. CommonSpirit Health is building a healthier future for all through its integrated health services. As one of the nation’s largest nonprofit Catholic healthcare organizations, CommonSpirit Health delivers more than 20 million patient encounters annually through more than 2,300 clinics, care sites and 137 hospital-based locations, in addition to its home-based services and virtual care offerings. CommonSpirit has more than 157,000 employees, 45,000 nurses and 25,000 physicians and advanced practice providers across 24 states and contributes more than $4.2 billion annually in charity care, community benefits and unreimbursed government programs. Together with our patients, physicians, partners, and communities, we are creating a more just, equitable, and innovative healthcare delivery system.

Job Summary / Purpose

Social Determinants of Health can have a major impact on a patient’s healthcare. As a member of a multidisciplinary team in the Outpatient CHI Health Clinics, the Social Worker-Outpatient Care Coordinator is responsible for assessing and providing support and intervention for the social and emotional needs of patients and their families to promote improved health, continuity of care and services in the outpatient setting. 

Works collaboratively with physicians, staff and other health care professionals within his/her clinically integrated network (CIN), CHI Health Partners, to maintain and improve quality and sustainability within the CIN. Includes:

• Understands and self-manages to support CIN-level success goals, including improvements in quality, cost of care and member experience for the CIN’s population.
• Identifies opportunities for improvement (at individual, clinic and CIN levels) and actively works with the healthcare and CIN team to correct or improve results.

Essential Key Job Responsibilities

1. Assists in the identification of member populations needing care coordination and social work intervention.
2. Acts as a liaison with patients and families to physicians, clinical staff, community resources and others.
3. Conducts a psychosocial assessment and acts as a patient’s advocate, by responding to and working with patients to address needs and resolve their concerns.
4. Provides Health Promotion activities and education for patients.
5. Functions as an active team member by effectively collaborating, communicating and coordinating among all responsible parties of an individual patient’s multidisciplinary health care team striving to eliminate fragmentation, duplication or gaps in health care.
6. Optimizes patient and family independence and self determination by  providing education and health coaching, and assisting with improving problem solving and coping skills as needed.  
7. Works with patients, families, and caregivers in the primary care and specialty clinics to address barriers that may be affecting the patient’s health, including, economic needs, behavioral issues, services in home, disability, out of home placement  etc. 
8. Identifies and links families to community resources.
9. Other duties as assigned within Population Health Care Management