Social Worker/LMSW - 90294

Department: Palliative Care Clinic

Hours Per Week: 8.00

Work Schedule: 8:00 AM to 4:30 PM

Salary Range: $20.27 - $30.90 Exempt: YesSummary: Works under the supervision of the Palliative Care Team. Serves in an expanded role to collaborate with patients, Palliative Care Providers, practice teams, all community agencies, including, but not limited to, behavioral health, housing authorities, Department of Health and Human Services, transportation and home health organizations, and other medical/specialty services to provide a model of care that ensures the delivery of quality, efficient, and cost-effective healthcare services. Assesses patient needs from a strengths based, person in environment manner, to design and implement coordinated intervention plans that monitor and evaluate options and services that aid towards meeting the shared goal of optimizing the patient's physical and bio-psycho-social-spiritual health status and lowering avoidable costs associated with less than optimal health and/or misuse/overuse of medical/community based services. The Social Worker works collaboratively within EMMC care coordination program and all care team members to ensure patient needs are met and care delivery is coordinated, and not duplicated, across the healthcare continuum. The expertise of the Social Worker is sought to assess and intervene with bio-psycho-social-spiritual barriers to patient's engaging with the healthcare system in a manner that promotes optimal health. Utilizes shared decision making models, collaboration, motivational interviewing, and other evidence based patient engagement, activation, and care coordination interventions to encourage positive behavior change in order to assist patients to achieve their highest level of function.

Responsibilities: Assists to develop coordinated care plans for patients with complex medical and/or behavioral health needs. Fosters a team approach by working collaboratively with all practice and community based team members, including but not limited to formal and informal supports such as: family members, neighbors, primary care providers and other members of the health care team, and community based supports to ensure coordination of services. Assist to identify outreach, wellness and education planning needs of the identified members and communicate findings to the Care Coordinator or CCT Lead. Coordinates referrals between and among physical and behavioral providers to necessary and appropriate community resources to assist patients to meet their goals and improve functioning. Ensures appropriate clinical information is shared timely with peers, providers and outside agencies while adhering to system privacy standards. Provide outreach, including telephonic, meetings or oral presentations, to community based and county transportation (or designated subcontractors) to assist members to access services. Works closely with payers to appropriately apply member benefits and serve as a resource to the member and healthcare team. Adheres to EMMC policies regarding member confidentiality. Maintains required documentation for all patient care activities. Collects required information and utilizes it to perform care coordination and collaborate with all team members to enhance patient care. Works with Palliative Care leadership to continuously evaluate process, identify problems, and propose process improvement strategies to enhance the Community Care Team, Patient Centered Medical Home, and Health Home Programs. Incorporates excellent written, verbal, and listening communication skills, positive relationship building skills, and critical analysis skills into social work practice. Performs social work activities, as set forth herein, in a variety of settings, including, but not limited to PCP offices, patient homes, hospital, or other community based settings as deemed appropriate for each individual high risk or complex patient in collaboration with Care Coordinator, contracted home health agency or primary care provider and all other service and health providers who the patient is working with. Develop collaborative relationships with community based agencies to understand and disseminate program and service eligibility, thus allowing for efficient use of referral systems aimed at improving care. Utilizes appropriate conflict resolution, assertiveness, advocacy, brokerage, negotiation, and collaboration skills in facilitating patients' movement throughout the health care continuum. Acts as a care partner to Care Coordination, Patient Centered Medical Homes and Health Home programs to assist practice members to appropriate referral sources. Participates in all required training and supervision to maintain State of Maine Social Work licensure. Utilizes evidence based screening tools to gather information related to barriers, strengths, and symptoms, which impact patient function. Shares information with practice team in order to enhance and improve outcomes. Performs duties as required or assigned by emergency or other operational reasons for which the employee is qualified to perform. Competencies and Skills: Behaves with Integrity and Builds Trust: Acts consistently in line with the core values, commitments and rules of conduct. Leads by example and tells the truth. Does what they say they will, when and how they say they will, or communicates an alternate plan. Cultivates Respect: Treats others fairly, embraces and values differences, and contributes to a culture of belonging, empowerment, and cooperation. Fosters Accountability: Creates and participates in a work environment where people hold themselves and others accountable for processes, results and behaviors. Takes appropriate ownership not only of successes but also mistakes and works to correct them in a timely manner. Demonstrates understanding that we all work as a team and the quality and timeliness of work impacts everyone involved. Practices Compassion: Exhibits genuine care for people and is available and ready to help; displays a deep awareness of and strong willingness to relieve the suffering of others.

Credentials: Required Licensed Master Social Worker

Education: Required Master's Degree

Working Conditions: Potential exposure to diseases or infections. Potential exposure to noise levels being uncomfortable. Work with computers, typing, reading or writing. Lifting, moving and loading less than 20 pounds. Prolonged periods of sitting. Prolonged periods of standing. Prolonged periods of walking. Northern Light Eastern Maine Medical Center is a 411-bed, regional tertiary care hospital and an American College of Surgeons-verified Level II Trauma Center. Located in Bangor, Maine, it serves as the principal referral center for a patient population of 500,000 residents across the northern two-thirds of the state. The medical center provides comprehensive inpatient and outpatient services, including advanced surgical care, neurosciences, cardiovascular medicine, oncology, and critical care. Eastern Maine Medical Center is the base for LifeFlight of Maine, a critical care air medical transport program that conducts nearly 900 missions annually, ensuring timely access to specialized care for rural and remote communities. As a member of Northern Light Health, the medical center is part of an integrated statewide health system comprising nine hospitals, numerous primary and specialty care practices, long-term care facilities, home health and hospice agencies, and emergency ground and air transport services. This integrated model supports coordinated, patient-centered care across the continuum. Eastern Maine Medical Center plays a central role in advancing clinical quality, operational efficiency, and health equity throughout the region. It is actively engaged in clinical education and serves as a training site for medical students, residents, and fellows through affiliations with academic and professional institutions. Bangor, Maine offers a stable and supportive environment for healthcare professionals. The region is home to high-performing public and private schools, including the University of Maine's flagship campus in Orono. Bangor International Airport provides convenient commercial air service with direct and connecting flights to major US hubs. The area also offers access to a wide range of cultural, educational, and recreational opportunities, with outdoor activities available year-round in Maine's forests, lakes, mountains, and coastal regions. Northern Light Eastern Maine Medical Center is a strategic hub for clinical excellence, innovation, and community health in northern New England. Questions? Contact Talent Acquisition: phone: 207-973-7100 email: talentacquisition@northernlight.orgEqual Opportunity Employment We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, age, disability status, gender, sex, sexual orientation, gender identity, ancestry, protected veteran status,