Medical Social Worker- Bakersfield 1.1

Medical Social Worker

Candidates with either a Bachelor's or Master's degree in Social Work, Psychology, Counseling, or a related behavioral science field are encouraged to apply!

Location: Bakersfield, CA. (Onsite)

Classification: Full-Time

This position is non-exempt and will be paid on an hourly basis.

Schedule: Monday-Friday 8am-5pm

Benefits:

• Medical
• Dental
• Vision
• Paid Time Off (PTO)
• Floating Holiday
• Simple IRA Plan with a 3% Employer Contribution
• Employer Paid Life Insurance
• Employee Assistance Program

Compensation: The initial pay range for this position upon commencement of employment is projected to fall between $28.15-$35.18 for a non-masters prepared and $33.53- $41.90 for a mastered prepared. However, the offered base pay may be subject to adjustments based on various individualized factors, such as the candidate's relevant knowledge, skills, and experience. We believe that exceptional talent deserves exceptional rewards. As a committed and forward-thinking organization, we offer competitive compensation packages designed to attract and retain top candidates like you.

Position Summary:

The Medical Social Worker is responsible for addressing the clinical and non-clinical needs of members with the most complex medical and social needs through systematic coordination of services and comprehensive care management. ECM is intended to be interdisciplinary, high touch, person-centered and provided primarily through in-person interactions with members where they live, seek care, and/or prefer to access services. The Medical Social Worker works with members that have chronic health conditions, are homeless or at-risk, with high hospital admissions, substance abuse, behavioral needs, and/or transitioning from incarceration. Using excellent communication skills, Medical Social Worker will provide services and coordination with members to ensure continuity of care across health and social service programs and community based and long term-support service (LTSS) programs. This position requires strong interpersonal and organizational skills to build rapport with members, coordinate referrals, and care amongst various healthcare providers and community services. The Medical Social Worker also works with the member's inter-disciplinary team (ICT) supporting the member and engages the member and the member's support systems to define priorities that are central to the member's desired needs and goals.

Job Duties and Responsibilities:

• Effectively manage and maintain a caseload of ECM members with higher behavioral and social acuity/ risk tier levels.
• Conduct a comprehensive assessment to develop a comprehensive, individualized, person-centered care plan with input from the member (and/or their parent, caregiver, guardian) to prioritize, address, and communicate strengths, risks, needs, and goals.
• Supports members with behavioral health conditions, with particular attention to members with SMI and/or SUD needs, through brief interventions, behavioral activation strategies, and linkages to community resources.
• Provide formal and informal training and support for ECM members on behavioral health conditions, including treatments and evidence-based for treatment.
• Tracks medical and behavioral health outcome measures in the web-based care management platform or equivalent platform.
• Responsible for building and maintaining a positive working relationship with Providers, including, but not limited to, communication via in-person, over the phone, and through digital means such as email and fax.
• Responsible for engaging with members, both in-person and on the phone, in a manner that utilizes evidence-based approaches (such as Motivational Interviewing) that promotes collaboration between the member and his or her medical/behavioral team, as well as to increase the member's sense of control over their whole health.
• Conduct in-person outreach and enrollment in community settings such as shelter, navigation sites, schools, substance use centers, churches—etc.
• Responsible for brief crisis interventions and warm hand-offs to local crisis resources as needed to address behavioral health needs.
• Engage with each member (and/or their parent, caregiver, guardian) authorized to receive ECM primarily through in-person contact and provide culturally appropriate and accessible communication.
• Identify necessary clinical and non-clinical resources that may be needed to appropriately assess member health status and gaps in care and may be needed to inform the development of an individualized Care Management Plan.
• Ensure member's care plan, incorporate identified needs and strategies to address needs, including, but not limited to, physical and developmental health, mental health, dementia, SUD, LTSS, oral health, palliative care, necessary community-based and social services, and housing.
• Ensure the member is reassessed at a frequency appropriate for the member's individual progress or changes in needs and/or as identified in the Care Management Plan.
• Ensure the Care Management Plan is reviewed, maintained, and updated under appropriate clinical oversight. Perform care coordination of care services necessary to implement the care plan.
• Gather information, present, and participate in Interdisciplinary Care Team (ICT) meetings.
• Organize member care activities, as laid out in the care plan; sharing information with those involved as part of the member's multi-disciplinary care team; and implementing activities identified in the care plan.
• Provide support to engage the member in their treatment, including coordination for medication review and/or reconciliation, scheduling appointments, providing appointment reminders, coordinating transportation, accompaniment to critical appointments, and identifying and helping to address other barriers to member engagement in treatment.
• Communicate the member's needs and preferences in a timely manner to the member's multi-disciplinary care team.
• Ensure regular contact with the member (and/or their parent, caregiver, guardian) when appropriate, consistent with the care plan and to monitor the member's conditions, health status, care planning, medications usages and side effects.
• Ensure care is continuous and integrated among all service Providers and referring to and following up with primary care, physical and developmental health, mental health, SUD treatment, LTSS, oral health, palliative care, and necessary community-based and social services, including housing, as needed.
• Provide services, such as coaching, to encourage and support members to make lifestyle choices based on healthy behavior, with the goal of promoting effective self-management skills.
• Support members in strengthening skills that enable them to identify and access resources to assist them in managing their conditions and preventing other chronic conditions.
• Use evidence-based practices, such as motivational interviewing, to engage and help the member participate in and manage their care.
• Provide transitional care services, including completion of discharge risk assessment and coordinating any follow up provider appointments and support services to facilitate safe and appropriate transitions from one setting or level of care to another.
• Coordinate medication review/reconciliation and provide adherence support and referral to appropriate services.
• Determine appropriate services to meet the needs of members, including services that address SDOH needs, including housing, and services offered by Community Supports.
• Coordinate and refer members to available community resources and follow up with members (and/or parent, caregiver, guardian) to ensure services were rendered (i.e., "closed loop referrals").
• Work collaboratively with other staff (LVNs, MAs, MSW, and non-clinical ECM staff) to provide quality assurance review of clinical documentation and implementation of ECM activities, including documentation of comprehensive assessments, transition of care follow-up, medication reconciliation, and development and implementation of care plans.
• Ensures documentation is accurate and in compliance with regulatory requirements and accreditation standards.
• May support the leadership team in ensuring compliance with regulatory requirements.
• Attend mandatory departmental and staff meetings.
• Assist with training and orientation of new staff.
• Other duties as assigned.

Qualifications:

• Possession of a master's degree from an accredited college or university with a major in Social Work, Psychology, Counseling, or a closely related behavioral science field.
• Experience: Two years of full-time experience providing counseling and/or social work services to medical patients.
• Substitution for Education and Experience: Possession of a Baccalaureate Degree from an accredited college or university with a major in Social Work, Psychology, Counseling, or a closely related behavioral science field and either: a) two years of full-time or its equivalent experience as a Medical Social Worker I or b) three years of full-time or its equivalent experience providing counseling and/or social work services to