Job description

Position Summary:

Reporting to the Community Care Manager, or to the Community Care Supervisor, MSW, and as a member of the Care Management Team, the Social Worker supports the development and monitoring of the plan of treatment for a caseload of program participants, and provides community-based (in-home and telephonic) evaluation of services to ensure the health, safety, and well-being of vulnerable and high-risk populations. This includes supporting transfer coordination, discharge planning, and issuance of all appropriate authorizations for covered services as needed by members. This position provides social services support such as participant screening, case management, counseling and referral.

Essential Functions of the Job:

• Responsible for the proactive management of acutely and chronically ill patients with the objective of improving health outcomes and costs by providing the social services support critical to delivering the participant plan of treatment that reflects an comprehensive needs assessment, intervention development, and support.
• Conducting a comprehensive health and psychosocial assessment of participants’ medical needs, diagnosis, functional and cognitive abilities, and environmental and social needs, to determine which service(s) are required to meet participants’ needs and preferences in the community.
• Working with the participants, their legal representatives, circles of support, and/or primary care physicians and providers to:
• Develop goals associated with the participant’s assessed needs, individual circumstances, and preferences.
• Mitigate risk and minimize disruptions in services.
• Identify when services identified in the POT are available through friends, family, and/or publicallyfunded programs.
• Implement the POT, which includes identifying service providers and community resources to help assure the timely, effective, and efficient mobilization and allocation of the services.
• Identify (and train, if necessary), backup caregivers who are willing and able to provide unpaid support if and when waiver service providers do not arrive when scheduled.
• Provide information, education, counseling, and advocacy to, and on behalf of, participants.
• Monitoring the delivery of HCBA Waiver services to ensure participants are receiving services as authorized in their POTs.
• Monitoring the quality of the authorized services by maintaining ongoing contact with HCBA Waive Program participants (including a monthly face-to-face visit or telephone call) to monitor for changes in health, mood, social integration, functionality, and overall well-being.
• Conducting annual face-to-face visits for HCBA Waive Program participants, reassessments, and care plan updates; and, following up with the participant after Emergency Department and inpatient facility admissions.
• Develop resources and refer patients and families to appropriate community agencies or facilities, acts as liaison with such organizations and as advocate for participants.
• Maintain accurate HCBA Waive Program case management records and timely documentation standards.
• Consult with and advise staff members as to the relationship of social, emotional and cultural factors to health and medical care, and as to the availability of social services in the community.
• Maintains a working knowledge of facility service areas including transportation, community characteristics and geography.
• Maintains a networking liaison with other organizations to address a broad range of social service needs. May be requested to represent the agency in contact with human service, health care, and community organization groups and individuals.
• Attend meetings, teleconferences, and trainings; or ensure a knowledgeable proxy attends in the place of the program lead to ensure the transfer the information.
• Participates as a clinical consultant within the Homes Health Program to review and inform regarding the participants health action plan, act as clinical resource for care coordinators, as needed; and facilitate access to primary care and behavioral health providers, as needed to assist care coordinators.

Additional Duties and Responsibilities

• Works independently and as an effective member of the team.
• Multi-tasking in regards to projects and their respective activities, timelines and issues.
• Demonstrate ability to inter-relate with physicians, nurses, patients, internal departments, outside agencies, and the general public.
• Demonstrate customer-focused service skills.
• Knowledge of HMO and Waiver program regulations related to eligibility requirements and plan specifics.
• Basic physical, psychosocial, and functional assessment skills.
• Able to collaborate between organizational and community resources.
• Thorough knowledge of appropriate utilization of acute hospital, long-term care and home care resources.
• Able to document concise yet thorough clinical documentation of patient assessment and care needs.
• Demonstrated strong communication and customer service skills, problem solving, critical thinking, time management, organizational skills and clinical judgment abilities.
• Familiarity and ability to use computers as well as EHR’s.
• Complies with all department, organization and government policies & procedures.
• Attends meetings and trainings as required.
• Adheres to and models SYH’s core values and behaviors of Excellence, Empowerment, Integrity and Respect.
• Adheres to SYH attendance and punctuality policies and practices.
• Provides after hours emergency response in the event of a natural disaster or crisis (including but nonlimited to, flooding, earthquakes, fires, power outages, etc.).
• Performs other duties as assigned

Job Requirements
Education Required (Minimum level of education):
Minimum: Master's Degree in Social Work, Gerontology, Psychology or Marriage Family Therapy, from an accredited School.

Preferred: First Aid/CPR certification. Certifications/Licenses Required: CA valid driver’s license and reliable transportation and proof of current vehicle insurance (if applicable) Experience Required (Minimum level of experience):

•2 years of experience working in a managed care health plan or•2 years of experience in utilization review, case management, and/or discharge planning or
•2 years of experience in transitional care and acute care settings (critical care, acute hospital care,long term acute care, skilled nursing care, long term care)•
Knowledge of and/or experience with Managed Care Health plans, Medi-Cal/Medicaid, and/or Medicare

Experience Preferred:

•Knowledge of managed care regulations (state and federal)

•Principles and practices of health care service delivery, managed care, health care systems, andmedical administration

•Experience performing audits analyzing productivity and quality of utilization management

•Knowledge and/or experience with the senior care market, including competitors, regulations, and available resources

Technical knowledge and skills required to perform the job:
Must thrive within a team environment, possess good organizational skills, and have the ability to effectively handle difficult and unusual interpersonal situations. Good knowledge of Microsoft Applications including Word, Excel, Access and Power Point. Computer data entry, analysis and reporting experience required. Knowledge of Electronic Health Data Systems including NextGen preferred.

Competencies:
Demonstrated ability to be culturally sensitive and respect diversity, work effectively with individuals of different cultures and socio-economic status; passion for service; self-starter and highly organized; ability to prioritize and complete a large volume of work within strict deadlines; provide prompt, efficient and responsive customer service.

Equipment used:
Personal vehicle, computers, phones, copy machines, fax machines and other general office equipment.

Working Conditions and Physical Requirements:
Physical clearance for reaching, bending, stooping, crouching, kneeling and grasping; have full range of motion; ability to lift 50 lbs; T.B. clearance; must maintain current First Aid and CPR. Frequent standing and walking indoors and outdoors; Will be required to travel to other sites or other locations in San Diego County; Will be required to work some evenings and/or weekends.

Job Type: Full-time

Pay: $31.36 - $46.88 per hour

Benefits:

• Health insurance

Schedule:

• 8 hour shift
• Weekend availability

Education:

• Master's (Required)

Work Location: Hybrid remote in Chula Vista, CA 91911

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