Social Worker

Written by chenmed - - Comments Off on Social Worker
June 23, 2021
Lauderhill, Florida
Job Type



Social Worker

This job is available in 3 locations

Category Medical Center Support Job Id R0018358

ChenMed is transforming healthcare for seniors. We provide big answers to big problems in health care delivery.  ChenMed is a full-risk primary care market leader with an innovative philosophy, unique physician culture and end-to-end customized technology. These things allow us to provide world-class primary care and coordinated care to the most vulnerable population – moderate- to low-income seniors who have complex chronic diseases.

Through our innovative operating model, physician-led culture and empowering technology, we are able to drive key quality and cost outcomes that create value for patients, physicians and the overall health system.  Our model allows us to practice medicine the way it should be practiced. By recruiting focused physicians and reducing their doctor-to-patient ratios, we increase patients’ “face time” during each monthly appointment and help foster stronger doctor-patient relationships. Our model also drives and enhances compliance with treatment plans.

As a result of our efforts, our patients realize lower hospital admissions. Their overwhelming response to our approach is reflected in our aggressive, organic growth and net promoter scores in the low to mid 90s, which is unheard of in any industry. Read more about our results and the value of the ChenMed model.

As a company, we are making a difference in the lives of seniors and the health care system overall.


  • Assists with the management and plan for transitions of care, discharge and post discharge follow up for HPP patients
  • Assess the patients for psychosocial, financial, family issues, palliative care/end of life issues, home safety, etc. that contributed to the hospitalization and/or could contribute to future hospitalizations.
  • Assess patients for Medicaid criteria and assist with application process as needed.
  • Assessments will be conducted in the center office, by phone call or patient’s home. Could occur in hospital/SNF as needed,
  • Collaborates with clinical staff in the development and execution of the plan of care and achievement of goals.
  • Supports the integration of social services/case management functions in the pre-acute, ER, acute and post-acute setting.
  • Coordinates with the case manager, patient and family, support the patient transition to the appropriate/least constrictive level of care assuring needed resources are in place.
  • Introduces self to patient/family and explain community social worker role and procedure to contact for needed resources.
  • Coordinates obtaining community resources/services that the patient needs and qualifies for as appropriate, e.g., Medicaid, meals, medications, housing, daycare, DME, HHA. etc.  If skilled needs or needs for DME are identified, discuss with PCP and make referrals to preferred providers.
  • Provides high intensity engagement with patient and family.
  • Facilitates patient/family conferences as needed to review goals of treatment, patient personal goals of care, and life planning.
  • Enhances a collaborative relationship to maximize the patient’s/family’s ability to make informed decisions.
  • Participates in Super Huddles as appropriate.
  • Maintains clinical and progress notes for each patient receiving care and provide progress report to PCP and others as appropriate.
  • Submits required documentation in a timely manner and in appropriate computer system.
  • Provides social services to patients, families, and significant others to enable them to deal with the impact of illness on individual family functioning and to achieve maximum benefits from healthcare services.
  • Serves as a patient advocate.
  • Other duties as assigned and modified at manager’s discretion.


  • Knowledge of case management theory and practice.
  • Knowledge of social services documentation procedures and standards.
  • Knowledge of community health services and social services support agencies and networks.
  • Knowledge of normative changes (e.g., sensory, cognitive, psychosocial) associated with aging and older adulthood.
  • Knowledge of advance care planning and palliative care, and related skill in addressing advance care planning
  • Knowledge of normative changes (e.g., sensory, cognitive, psychosocial) associated with aging and older adulthood.
  • Knowledge of advance care planning and palliative care, and related skill in addressing with patients and/or their family systems.
  • Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.
  • Critical thinking skills required.
  • Skill in communication with and psychosocial support of patients with cognitive impairment.
  • Skill in psychosocial interventions with challenged caregivers/family systems of high-risk patients.
  •  Skills in organizing and coordinating.
  • Ability to work autonomously is required.
  • Ability to monitor, assess and record patients’ progress and make adjustments accordingly.
  • Ability to communicate technical information to non-technical personnel

with patients and/or their family systems.

  • Appropriate utilization of community-based resources.
  • Proficiency in written communication:  documentation is clear, concise, accurate, provides meaningful communication and is consistent with ChenMed policy and regulatory requirements.
  • Ethical practice behavior consistent with ChenMed policies and professional standards.
  • Appropriate utilization of community-based resources.
  • Proficiency in written communication:  documentation is clear, concise, accurate, provides meaningful communication and is consistent with ChenMed policy and regulatory requirements.
  • Teamwork skills in care coordination with patients, family systems, ChenMed staff and external providers.

At ChenMed,  If you are an innovative, entrepreneurial minded, over-achiever who is extremely passionate in helping people and revolutionizing Healthcare again, we are that dynamic and exciting company you are looking for!

After applying, we encourage you to "follow" us on LinkedIn (ChenMed) as well! This way you can stay informed and up to date on what’s happening around our organization and start your path to becoming part of our FAMILY!


  • Bachelor's degree in Social Work is required (BSW) from accredited university. Master's Degree in Social Work is preferred.
  • Minimum of 2 years of social work, case management, and/or discharge planning experience is preferred.
  • Hospital, healthcare setting experience is preferred.
  • Strong interpersonal, communication and critical thinking skills are required.
  • Ability to work autonomously is required.
  • Minimum two (2) years of clinical experience.
  • Minimum of one (1) years of case management, home health, and/or discharge planning experience is preferred.
  • Certified Case Manager certification is preferred.

The Community Social Worker overall goal is to help people who have chronic, life threatening or altering diseases and disorders to connect with plans and resources to help them maintain an optimum level of health. The incumbent advocates for services and resources for the underprivileged and victims of abuse, neglect or other difficult family situations. Additional duties and responsibilities include working closely with the nurse case managers to transition patients to the appropriate level of care post hospital/SNF discharge and may perform post discharge follow up in the home. The social worker will adhere to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance, and policies and procedures. Supervision is received from a Director who evaluates quality of results through personal conferences and analysis of records and activity reports.


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Life at ChenMed

phenom culture
Culture We’re working together to build strong communities inside and outside.
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Benefits ChenMed sees the whole person and looks to support your well-being.
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Meet Our Team

Nestor Arias
“I love that I get to teach our clinicians and non-clinicians things that I am passionate about...I also love working for a company that truly improves the quality of life for our seniors.” Nestor Arias, Senior Training Specialist
“I truly love ChenMed’s vision and mission. It’s the right way to treat patients and the way I treat my family.”

David Guerra MD, Medical Director

David Guerra MD
Backy Miller
“I came to ChenMed because it fulfills my purpose as a person. Those who work for this company are very special, and they have the opportunity to do something life-changing.” Lynette Acosta, Center Manager
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