BSW Social Worker / Case Manager

Job Description

Job Description

Description:

Job Type: Full-Time
Schedule: Monday–Friday, 8-hour shift
Pay: $24.00–$25.00 per hour, depending on experience

Access TLC is a Home and Community-Based Alternatives (HCBA) Waiver Agency contracted with the Department of Health Care Services (DHCS). The HCBA Waiver Program provides comprehensive care management services to individuals at risk of nursing home or institutional placement.

Our multidisciplinary care management team, comprised of a Registered Nurse and Social Worker, coordinates Waiver and State Plan services, including medical care, home health, In-Home Supportive Services (IHSS), and other long-term supports. Services are provided in the participant’s community-based residence, which may be privately owned, leased, or a family member’s home.

This position does not provide clinical hours toward licensure . If you are seeking supervised clinical hours to meet licensing requirements, this position will not fulfill those requirements.

The BSW Social Worker/Case Manager works as part of a multidisciplinary care management team to support HCBA participants in accessing appropriate healthcare, social services, community resources, and long-term supports. The position requires strong communication, organization, documentation, and case management skills, as well as the ability to work independently while collaborating closely with Registered Nurses, participants, families, providers, and community agencies.

• Collaborate with Registered Nurses, staff, and management to ensure compliance with DHCS rules, regulations, and HCBA program requirements.
• Work directly with HCBA participants, legal representatives, family members, support systems, and healthcare providers to provide education, support, advocacy, and resource coordination.
• Conduct psychosocial and needs-based assessments and identify barriers affecting the participant’s health, safety, independence, and overall well-being.
• Develop individualized goals based on participant needs and assist participants in connecting with appropriate community and social service resources.
• Partner with the Registered Nurse to develop and implement a Plan of Treatment (POT) based on identified needs, concerns, and interventions.
• Coordinate with healthcare providers, social service agencies, home health providers, IHSS, and other community resources to facilitate timely and effective services.
• Conduct monthly case management calls to monitor the participant’s health status, mood, social integration, functional abilities, living situation, and overall well-being.
• Maintain accurate and timely case notes, assessments, care coordination documentation, and utilization management entries in the MedCompass health management system.
• Monitor participant needs and changes in circumstances and communicate concerns to the appropriate members of the care team.
• Complete Adult Protective Services (APS) referrals and other mandated reports when required.
• Follow up on concerns involving abuse, neglect, exploitation, changes in condition, or safety risks.
• Advocate for participants’ needs and assist with identifying resources that promote community living and prevent unnecessary institutionalization.
• Maintain confidentiality and comply with applicable privacy, documentation, and regulatory requirements.
• Perform other case management and administrative duties as assigned.

• Bachelor’s Degree in Social Work (BSW), Psychology, Counseling, Rehabilitation, Gerontology or Sociology 
• Strong understanding of social, emotional, and functional issues affecting older adults, individuals with disabilities, and individuals with complex medical needs.
• Previous experience in social services, case management, care coordination, healthcare, or a related field preferred.
• Strong organizational and time-management skills with the ability to prioritize multiple cases and responsibilities.
• Excellent attention to detail and documentation skills.
• Strong problem-solving and critical-thinking abilities.
• Excellent verbal and written communication skills.
• Ability to work independently and effectively as part of a multidisciplinary team.
• Proficiency with Microsoft Office, including Outlook and Excel.
• Ability to learn and effectively use electronic health records and case management systems.

• Experience working with individuals with complex medical conditions, disabilities, mental health or behavioral health needs, and/or substance use disorders.
• Experience with care coordination, case management, community-based services, or long-term care.
• Knowledge of community resources and social service programs.
• Experience working with older adults and/or individuals at risk of institutional placement.
• Bilingual Vietnamese/English strongly preferred.
• Ability to travel to participant homes and community locations as required.

• $24.00–$25.00 per hour , depending on experience
• Bilingual Vietnamese/English bonus available upon successful completion of the introductory period
• Health Insurance
• Dental Insurance
• Vision Insurance
• Life Insurance
• Paid Time Off (PTO)
• Retirement Plan