The primary focus of the Social Worker / Case Manager is to use a patient centered approach and effective communication to assist patients to cope with the social/emotional issues and practical arrangements related to the patient’s illness. Effective outreach and engagement strategies that establish trust and overcome barriers resulting from isolation, stigma, and the symptoms of mental health and/or substance use problems will be utilized. A sustained support model to meet basic needs and respond to individual preferences as well as trauma-informed services that restore hope will be utilized. The Social Worker is a member of the healthcare team providing assessments, coordination, treatment planning, information and referral to community resources and other social work services. The primary goal and offered individualized intensive case management services using a multidisciplinary approach, including, but not limited to: Mental health and substance abuse assessment; health system navigation; housing and benefits advocacy; health coaching, referrals and brief treatment, pharmacy consultation and supportive counseling.
Displays a willingness to explore and acknowledge patient needs, expectations and values. Responds in a way that is helpful and beyond expectation.
Uses effective communication skills and motivational interviewing techniques to obtain relevant psycho-social information from patients and families.
Identifies financial, environmental, emotional, and social factors which greatly contribute to the condition/illness or work against the ability of the patient and family/caregiver to benefit from medical and health care.
Creates and implements an efficient and sure social work treatment scheme for patients and families/caregivers based on analysis of the psycho-social factors as well as the medical illness of the patient.
Conducts home visits that would help identify the need for added equipment or service and arranges supportive services as appropriate.
Collaborates with primary care providers, the behavioral health clinician, pharmacist and other members of the treatment team through a multi- or interdisciplinary approach.
Assistance with establishing a medical home.
Assistance with obtaining primary medical care, including medical respite.
Assistance with obtaining behavioral health and/or substance abuse treatment.
Assistance with care coordination.
Outreach to home/shelter for supportive counseling & follow-up.
Assistance with obtaining SSI, public assistance
Provision of taxi vouchers and bus passes for transportation to appointments
Linkage of uninsured patients to Certified Enrollment Counselors
Linkage to emergency, transitional, and permanent housing
Linkage of chronic condition patients to health education services
Referrals to social services and community resources (e.g., legal assistance, food banks, money management)
Travel as required for training, meetings and to conduct job responsibilities.
Perform other duties as assigned
High School Diploma or GED with 6 years of experience, AA degree with 4 years of experience, Bachelor’s degree with 2 years of experience, or Master’s degree. A degree in psychology, social work, or behavioral science is highly preferred. Experience should reflect progressive responsibility in social work, case management, health education, or community health service programs.
Excellent knowledge and ability to learn computer programs such as Microsoft Office, Electronic Health Records, and patient tracking software
Strong communication/motivational interviewing and psychosocial assessment skills; effectively manage caseload. Prepare written and statistical reports.
Valid California driver's license, proof of auto insurance, and personal transportation
Preference for individuals with the ability to communicate in Spanish and English; verbal and written
Knowledge of principles and practices of social work and counseling techniques
Knowledge of community resources and referral agencies
Knowledge of group dynamics
Knowledge of office management principles and practices
Skill in counseling
Skill in interviewing and communicating to elicit information and cooperation from patients
Skill in establishing and maintaining effective working relationships with patients, staff, and the public
Skill in public speaking
Skill in facilitating support groups
Ability to write reports, correctly reflecting intervention and document progress
Ability to learn and explain complex policies/regulations that govern processes in specific programs.
TYPICAL PHYSICAL DEMANDS:
May require sitting for long periods of time; also stooping, bending and stretching for files and supplies. May require lifting up to 25 pounds. Vision must be correctable to 20/40 and hearing must be in the normal range for telephone contacts. Requires ability to drive to outreach areas for presentations and other activities.
TYPICAL WORKING CONDITIONS:
Work is performed in an office environment. Involves frequent contact with staff, patients and the public. Some extended workdays and weekends may be required. Work may be stressful at times. May require contact with individuals with communicable diseases. May encounter individuals who are violent, abusive and/or under the influence of alcohol or drugs.