Medical Social Worker, BSW

Position Summary:

Reporting to the HCBA Waiver Manager, 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 Home and Community Based Alternatives Waiver Program participants and provides community-based (in-home, telehealth, 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 a 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, working in conjunction with a registered nurse, 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 an effective Plan of Treatment (POT), including:
• Developing goals associated with the participant's assessed needs, individual circumstances, and preferences.
• Mitigates risk and minimizes disruptions in services.
• Identifies when services in the POT are available through friends, family, and/or other publicly funded programs.
• Implement the POT, including identifying service providers and community resources to help assure the timely, effective, and efficient mobilization and allocation of the services.
• Identify (and arrange training, if necessary), backup caregivers who are willing and able to provide unpaid support if/when waiver service providers do not arrive when scheduled.
• Provide information, education, counseling, and advocacy to, and on behalf of, participants.
• Routine monitoring of the delivery and quality of HCBA Waiver services to ensure HCBA Waiver participants are receiving services as authorized in their POTs, 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 routine annual face-to-face visits for HCBA Waiver 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 Waiver 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.
• Attending 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 interdisciplinary team.
• Time management in regard to projects and their respective activities, timelines and issues.
• Demonstrate ability to inter-relate with physicians, nurses, patients, internal departments, outside agencies, and the 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.
• Ability to use computers as well as EHR's.
• Complies with all department, organization and government policies & procedures.
• Attends meetings and training courses 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.
• Performs other duties as assigned.

Job Requirements

Education Required:

Bachelor's Degree in Social Work, Gerontology, Psychology, or Marriage Family Therapy from an accredited school.


Certifications/Licenses Required:

Valid CA driver's license, access to an insured vehicle, and ability to drive within San Diego County and possibly to Imperial County.

Experience and Required Skills:

A minimum 2 years of any combination of the below:

• 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).
• Must thrive within a team environment, possess good organizational skills, and can effectively handle difficult and unusual interpersonal situations.
• Good knowledge of Microsoft Applications including Word, Excel, and Power Point.
• Computer data entry, analysis and reporting experience required.
• Knowledge of Electronic Health Data Systems including Epic preferred.
• 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 and ability to lift up to 50 lbs.
• T.B. clearance.
• Frequent standing and walking indoors and outdoors.
• Will be required to travel to other sites or other locations in San Diego County.
• May be asked to work outside of normal business hours occasionally.

Universal Requirements:

Pre-employment requirements include I-9, physical, positive background and reference check results, complete application, new hire orientation, pre-employment PPDs.

About Us San Ysidro Health is a Federally Qualified Health Care organization committed to providing high quality, compassionate, accessible and affordable healthcare services for the entire family. The organization was founded by seven women in search of medical services for their families and community. Almost 50 years later, San Ysidro Health now provides innovative care to over 108,000 patients through a vast and integrated network of 47 program sites across the county. San Ysidro Health could not serve our patients without the dedication of our passionate and hardworking employees. Apply today and become a part of our mission-driven team! San Ysidro Health has a long-standing commitment to equal employment opportunity for all applicants for employment. Employment decisions including, but not limited to, those such as employee selection, performance evaluation, administration of benefits, working conditions, employee programs, transfers, position changes, training, disciplinary action, compensation, and separations are made without regard to race, color, religion (including religious dress and grooming), creed, national origin, nationality, citizenship status, domestic partnership status, ancestry, gender, affectional or sexual orientation, gender identity or expression, marital status, civil union status, family status, age, mental or physical disability (including AIDS or HIV-related status), atypical heredity cellular or blood trait of an individual, genetic information or refusal to submit to a genetic test or make available the results of a genetic test, military status, veteran status, or any other characteristic protected by applicable federal, state, or local laws.