Master Social Work at Suvida Healthcare LLC – Houston, Texas

Who We Are

At Suvida Healthcare, we are not just caregivers; we're compassionate advocates dedicated to enriching the lives of our cherished seniors. As a Team Member with us, you will embark on a fulfilling journey where your skills and empathy converge to make a meaningful impact on the well-being of an underserved community and their families. Our multi-disciplinary primary care program is built to address the physical, behavioral, social, and cultural needs of Medicare-eligible Hispanic seniors.

Celebrate diversity and inclusivity in a workplace that attracts, engages, values, rewards, and recognizes the unique needs and backgrounds of both, our patients and our team. We believe that a rich tapestry of experiences, shared interests, and perspectives enhances the care we provide, making us a stronger, service-centered, and more compassionate healthcare family and Employer of Choice! Will you join us Suvidanos, to help achieve our Higher Purpose?

What Makes Us Unique

We are an empowered primary care, clinical operations, and support team creating health equity through an exceptional clinical and consumer experience that improves the quality of life for the people, families, and neighborhoods we serve. We tailor our primary care program to the culture, language, social, and overall well-being of the seniors we serve.

How We Work

Our Culture & Core Beliefs

Earn TrustBuilding RelationshipsCreating JoyDoing RightImproving Every DayMoving Forward

What You’ll Do

What You’ll Do - Job Responsibilities

The Senior Guia systematically intervenes to provide clinical social work and complex case management to patients and their families who have complex psychosocial needs, require assistance with eligibility determination for social programs and funding sources, and qualify for community assistance from a variety of special funds and agencies. This position assesses the patient’s plan of care and develops, implements, monitors, and documents the utilization of resources internally and externally and progress of the patient through the continuum of care. The intensity of care coordination provided is situational and appropriate based on patient need and payer requirements. This role participates in an interdisciplinary team (including Physicians, Case Managers, Staff Nurses and other members of the care team) to provide services for high-risk patients and ensure that psychosocial needs are attended to and treated as required across the continuum of care. Essential responsibilities consist of but not all inclusive:

Provides comprehensive care coordination to an assigned patient caseloadWorks collaboratively with patients, family, caregivers, healthcare providers, and external partners to meet complex medical patient needsAs part of a multidisciplinary team, develops and carries out a treatment plan by the use of a clinical social work diagnosis, assessment and treatment interventionsIntervenes with patients and families regarding emotional, social, and financial consequences of illness and/or disabilityAssesses, mobilizes and provides follow up on family/community resources to meet social care needsProvides intervention in cases involving elder abuse/neglect, domestic violence, guardianship (temporary/permanent), mental health placement, and sexual assaultInitiates and assists patients with advance directivesCollaborates with patients/caregivers to include supportive care, end-of-life decisions, community resources/programs, goal setting, and long-term planning needsFormulates care plan of intervention acceptable to the patient, family, and health care teamReceives referrals for complex patient problem resolution from case managers or clinical care team membersWorks in collaboration with the clinical and case management team on transitions of care planning and referrals to post-acute providersPromotes a collaborative process and communication between all health care team members, internal multidisciplinary teams, inclusive patients/clients, families, and significant others to ensure the process of integrated care services are targeted, appropriate, and beneficialAdvocates utilizing knowledge of applicable laws, regulations, government, and insurance benefits as well as practice guidelines and standards of practiceAdvocates for patient and family empowerment and independence to make autonomous health care decisions and access needed services within the health care systemProvides follow up and assistance to patients in a variety of settings: in-home, in-clinic, and in the ancillary setting- hospitals, group homes, skilled nursing facilities, etc.Documents all interventions in the patient medical record both timely and accurately including all elements of clinic visits, in home, telephonic engagement, or textingMaintains knowledge of Medicare, Medicaid, and other program benefits to assist patients with resource allocation and choicesHas freedom to determine how to best accomplish functions within established proceduresProvides consultation to low risk guias on patients with significant or intensive community resources needsParticipates in the development and maintenance of case management metricsProvides professional education to staff and communityFacilitates Suvida sponsored support groupsOther duties as assigned by Guia Manager

What You’ll Bring - Education Requirements

Graduate of an accredited Master of Social Work program (MSW) preferred.Requires a Licensed Master Social Worker (LMSW) or equivalent 3-5 years of experience AND CHW certification plus 6- 8 years social work experience.Must have knowledge of government/community resources as well as Medicare, Medicaid, long-term care, or any other applicable resources/services.Must have knowledge for transacting LIS, PAP, and SNAP applications and other foundation applications.Must demonstrate critical thinking skills, problem-solving abilities, effective communication skills, relationship building skills, and time management skill.

What You’ll Bring - Experience Requirements

Acute inpatient hospital social work experience preferred.Experience managing the needs of Senior/Geriatric populations.Experience assessing and addressing the social determinant of health.Working knowledge of ICD-10 and Z codes.Proficiency with EMRs, computers, mobile devices, medical devices, and Microsoft Office Suite.Excellent therapeutic communication and negotiation skills in interactions with patients, families, physicians, and health care team colleagues.Exposure and/or experience in pre-acute and post-acute care.Expertise connecting patients and ensuring closed loop referral with community resources and governmental agencies that address complex social needs.Ability to work independently, as well as, to develop collaborative relations with physicians, families, patients, interdisciplinary team members, and community agencies.Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components.Effective oral and written communication skills.Teamwork and management of personnel experience.Experience utilizing electronic medical records and social service referral management software.Ability to communicate and effectively interact with people across cultures, ranges of ability, genders, ethnicities, and races.Comfort and ability to care for patients in-home, in-clinic, and in the ancillary setting- hospitals, group homes, skilled nursing facilities, etc.Supports departmental goals which contribute to the success of the organization and serves as preceptor, mentor, and resource to less experienced staff.Compassionate, kind, generous, and open-minded.Ability to promote individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency.Bilingual/Bicultural (English and Spanish) Required.

Physical Demands

While performing the duties of this job, the employee is required to sit for prolonged periods of time, stand, walk, talk, hear, and reach with hands and arms. Hand eye coordination is necessary to operate computers and other office equipment; must be able to operate a motor vehicle. When representing Suvida Healthcare at external events, the Senior Guia may also be required to stand for prolonged periods of time, kneel, crouch, bend and lift, and able to move up to 30 pounds. The work environment characteristics described here are representative of those employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Suvida Healthcare provides equal employment opportunities to all Team Members and applicants for employment and prohibits discrimination and harassment of any type with regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.