Salary: $24.34 - $35.11 Per Hour

If hired for this position, you will be required to provide proof that you are fully vaccinated for COVID-19 prior to your start date, or have a valid religious or medical reason qualifying you for an exemption (that may or may not require accommodation)

STAR Clinic MCWs work closely with the medical and social service team within the patient centered medical home (PCMH) to provide services to our most vulnerable, complex patients. The medical case worker is an integral part of the Behavioral Health Team at the STAR Clinic providing linkage and resources and case management services to patients assigned to the STAR Clinic. These patients typically have two or more uncontrolled chronic medical conditions, behavioral health issues, and social struggles such as homelessness, substance use disorder, social isolation, illiteracy, and poverty. The Medical Case Worker helps provide tangible support with needs to address social determinants of health such as housing, food security, and transportation. Assists with coordination of transition services to optimize patient in the community which may include home health, durable medical equipment, higher level of care, and linkage to a variety of community-based services/programs. They provide key interventions that include resource linkages and transitions of care support services after hospitalizations to prevent readmissions.They also provide linkages to community-based resources and provide arrangements for placement and continued care in the community.

ESSENTIAL FUNCTIONS

• Identifies and provides referrals for appropriate community resources based on assessments/screening results from other BH team member (SBDOH)
• Problem solves and coordinates patients’ transition of care needs to the community, addressing social determinants of health such as linkage to food, housing, and transportation resources
• Keeps informed on community health and welfare resources and the variety of programs offered by each
• Assists in the initial interview of new patients/clients at mental health clinics, learns to identify nature of problem and to make referrals to psychiatric team or outside clinics or community agencies
• Places patients/clients suffering with mental or emotional disorders in board and care homes, intermediate care homes, residential facilities, private hospitals, VA hospitals, and rehabilitation facilities, depending upon psychiatric reports and personal interviews with patient/client
• Participates in placing patients/clients who are suffering with mental or emotional disorders in board and care homes, intermediate care homes, residential facilities, private hospitals, VA hospitals, and rehabilitation facilities depending upon psychiatric report and personal interviews with patient/client
• Makes referrals to and works with various public and private health, mental health or other agencies such as the Department of Public Social Services, Legal Aid, Department of Adoptions, Health Department, Free Clinics, Planned Parenthood organizations, Family Service Agencies, and Community Service Centers to resolve patient’/client’s personal and social problems
• Assists the patient/client and family members with environmental difficulties precipitated by the illness by arranging for childcare services, for foster home, or by assisting to secure homemaker or attendant care services; assist with skilled nursing placement
• Identifies and reports suspected dependent adult, elder, child and partner/intimate partner violence
• Makes referrals to social welfare programs and community resources beneficial to the patient
• Places patients/clients suffering with mental or emotional disorders in board and care homes, intermediate care homes, residential facilities, private hospitals, VA hospitals, and rehabilitation facilities, depending upon psychiatric reports and personal interviews with patient/client
• Documents social history and identified problems problem-solving process and outcomes in electronic medical record
• Coordinates with external and internal agencies (e.g., DHS Managed Care Services, L.A. Care, and Health Net) to provide services or equipment (e.g., durable medical equipment, transportation, home health services, dialysis and self-administered medications) as ordered by the medical provider and according to approved workflows
• Completes Prior Authorization forms as needed. Consults with provider or Care Manager when clinical questions arise
• Assist with arrangements for patients needing placement to higher level of care, including but not limited to placement needs for residential treatment program, methadone treatment program, and/or psychiatric placements or referrals
• Collaborates with external / internal customers as needed to ensure that patient care needs are met
• Participates in clinic discussion, team conferences and provides relevant information to interdisciplinary team

NON-ESSENTIAL FUNCTIONS

• Participates in team huddles, case conferences, and multidisciplinary team meetings as needed
• Participates in performance/quality improvement (PI/QI) activities
• Shares knowledge and effective practices with other Care Team members.

JOB QUALIFICATIONS

• Existing relationships and trust within communities of focus
• Familiarity working with or navigating within the health and social services system, preferably as a result of lived experience
• Ability to build and maintain trusting relationships with community stakeholders and health and social service providers
• Ability to work independently in a constantly changing environment
• Personal strength, resilience, and stability to allow the CHW, with support of supervisor and work team, to face very challenging situations and avoid re-traumatization and vicarious trauma
• Demonstrated teaching and communication skills with clinical and non-clinical staff
• Familiarity with DMH, DPH and community mental health and substance use programs and resources
• Lived experience in one or more of the communities of focus: people experiencing homelessness, people coming out of incarceration, people with substance use disorder, people continuously admitted to hospitals due to homelessness, women with barriers to a healthy pregnancy, and people with mental illness
• Member of the community, close affiliation, or shared life experience with the community being served
• Ability to work appropriately and effectively with patients of the Star Clinic and clients of Housing for Health who reside in Skid Row and across 8 SPAs in Los Angeles County
• Potential or demonstrated community leadership
• Experience working with medically and socially complex individuals

Education/Experience

A Bachelor’s degree from an accredited college or university. One year of professional casework experience interviewing, counseling, and assisting patients/clients with social problems preferred.

Certificates/Licenses/Clearances

A valid California Class C Driver License or the ability to utilize an alternative method of transportation when needed to carry out job-related essential functions.

Other Skills, Knowledge, and Abilities

• Successful clearance through Los Angeles County’s Live Scan process.• Successful clearance through the Medical Clearance process.

PHYSICAL DEMANDS

Walk: Frequently

Sit: Frequently

Handling / Fingering: Occasionally

Reach Outward: Occasionally

Reach Above Shoulder: Occasionally

Climb, Crawl, Kneel, Bend: Occasionally

Lift / Carry: Occasionally - Up to 50 lbs

Push/Pull: Occasionally - Up to 50 lbs

See: Constantly

Taste/ Smell: Not Applicable

Not Applicable = Not required for essential functions