The Social Worker coordinates a comprehensive patient care plan for pregnant and postpartum families with the Nashville Strong Babies 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 all relevant patient assessments and evaluations according to project protocol and OB, Pediatric best practices. Conduct out of clinic visits with participants. Help each participant create an individual and family life plan, and work towards reaching goals. Schedule additional visits with high risk patients to maximize health and wellness outcomes. • Serves as a principal liaison between patients and medical providers; coordinates and follows clinic referrals and appointments. • 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. • Provide timely data and reporting to comply with all grant requirements. • Work with the Program Manager and key staff to develop and conduct quality assurance processes for client/site records. • Develop collaborative approach to service delivery through integration of activities and services across all programs and projects. • Identify existing and develop new resources and relationships with outside service providers. • Aide in coordination of group care between OB and Pediatrics
• Performs other related duties as assigned.
Required Skills
Basic knowledge of clinical psychology and best practices.
Knowledge to foster excellent culturally competent patient relationships
Ability to work independently, take initiative, prioritize duties and work closely with other programs/projects and multiple multidisciplinary partners.
Organized, detail-oriented and have the ability to handle a variety of tasks simultaneously with a problem-solving approach.
Strong communication skills, written and verbal, conflict resolution skills and asset mapping skills
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.
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.
Required Experience
Basic knowledge of clinical psychology and best practices.
Knowledge to foster excellent culturally competent patient relationships
Ability to work independently, take initiative, prioritize duties and work closely with other programs/projects and multiple multidisciplinary partners.
Organized, detail-oriented and have the ability to handle a variety of tasks simultaneously with a problem-solving approach.
Strong communication skills, written and verbal, conflict resolution skills and asset mapping skills
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.
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.