Overview

Provide a range of social work services in collaboration with PHC staff to meet the psycho-social and care coordination needs of members. Responsible for the assessment and care coordination of the psycho-social needs of members, families and/or caregivers to help promote positive coping skills, reduce the risk of premature institutionalization, assist individuals in maintaining independence in the community and increase stabilization of social determinants.

Responsibilities

• Travels to meet members, families and/or caregivers in the community to address case management and care coordination needs.
• Develops an individualized care plan addressing the psycho-social elements and non-medical barriers to health in an effort to promote and ensure optimal care coordination of the member’s needs.
• Conducts interview assessments with individuals, families and/or caregivers to identify a member’s needs, goals and/or barriers.
• Sets priorities according to treatment goals and member’s preferences in a timely manner.
• Supports successful transitions and coordination of services across the care continuum (ex: pediatric to adult settings, acute/post-acute to community, adaptation to disability or trauma, etc.) via effective and frequent communication and collaboration with providers, the member, family and/or caregiver.
• Arranges, coordinates and monitors the use of community services/resources available to members, family and/or caregivers. (ex: housing options, financial assistance, special education options, vocational training/employment, legal aid services, etc.)
• Assists members in selecting appropriate resources and/or contacting resources on behalf of the member. Provides support in obtaining necessary forms, filling out documents/applications when appropriate.
• Provides education and support to members, families, caregivers and/or PHC staff regarding conservatorship, Public Guardianship, Power of Attorney and/or Authorized Representative options for members with identified needs.
• Uses Motivational Interviewing strategies and clear communication/limit setting to promote member’s self-management, reduce risk of system(s) dependency, and improve health and well-being.
• Documents interventions and activities according to departmental policies and procedures.
• Collaborates with colleagues to provide education and support to members with identified psycho-social and/or resource needs.
• Participates as part of a multidisciplinary team in PHC’s integrated rounds; presenting complex member cases when needed and offering suggestions or support to others.
• Maintains working knowledge of public/private community resources and fosters collaborative working relationships on behalf of PHC.
• Actively participates in outreach meetings or case conferences in the community, including hospitals, skilled nursing facilities, community-based organizations, etc.
• Engages in essential skills training as directed or assigned.
• Other duties as assigned.

Qualifications

Education and Experience

Bachelors or Masters degree in Social Work, Minimum of two (2) years of social work in a healthcare or public health settingpreferred or equivalent work experience considered.

Special Skills, Licenses and Certifications

Valid CA driver’s license and proof of current Automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business.

Performance Based Competencies

Experience with human growth and development, group and family dynamics, principles of individual and group behavior, provisions of federal, state, and local welfare programs and the laws, rules, and regulations governing their applications: community organizations and resources: socioeconomic conditions and trends: current problems and methodology in public social service. Ability to: assess and evaluate data and develop an effective course of action; make effective use of resources and services in the community; develop and maintain effective working relationships with members, departmental staff, public and private Social Service agencies, community based organizations, and the public; control personal bias and apply social work ethics; input data, reports and narratives into a computer system; keep detailed records and prepare reports and correspondence. Bilingual skills in Spanish preferred.

Work Environment And Physical Demands

Daily use of telephone, fax, computer, and photocopying machine is required. Standard cubicle workstation with a shared common area. Must be able to lift, move, or carry objects of varying size, weighing up to 10 lbs. Frequent travel and/or field-based work (at least 50% driving travel required).

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

HIRING CHANGE:

$ 38.11 - $ 49.54

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.