Licensed Social Worker

Licensed Social WorkerThe Licensed Social Worker works within the interdisciplinary care team as part of the Care at Home Solutions program. As an independently licensed clinician, the Licensed Social Worker partners closely with the Medical Director, Advanced Practice Provider (APP), Registered Nurse (RN), Pharmacist, Community Health Worker (CHW), and Care Navigators to address behavioral health needs, improve psychosocial well-being, and support patients in achieving their health goals. The Licensed Social Worker conducts comprehensive behavioral health assessments, provides evidence-based counseling and brief interventions, develops individualized care plans, facilitates crisis intervention as appropriate, and connects patients with community-based behavioral health and social support resources. The Licensed Social Worker holds an active LCSW CA license or equivalent.FLSA Status - Exempt - Salary Range - $75,000 - $96,000Reports To - Director, Care at Home Solutions - Direct Reports - NoneLocation - Hybrid; LA Office - Travel - Up to 50%Work Type - Full-Time - Schedule - Standard business hours; flexibility based on patient and program needsDuties and Responsibilities (including but not limited to)Assess identified patients to determine appropriateness for management early in their disease process and at any time during the continuum of care.Complete a comprehensive assessment to identify patient risk and develop a care plan utilizing expertise and judgement to evaluate needs for alternative services as needed.Assess members' Social Determinants of Health, such as housing, food, transportation, and safety in the home.Work collaboratively with APPs, physicians and community resources including pharmacists, nurses, registered dieticians, and other disciplines to address patient needs as identified in assessments.Assess and screen members for behavioral health concerns (depression / substance abuse) utilizing screening tools, including the PHQ2 and 9 Depression screenings, and ensure they are receiving appropriate behavioral health interventions.Facilitate any necessary follow-up or referrals for behavioral health needs with local behavioral health providers.Develop, facilitate, and communicate a plan of care in partnership with the member, family (or designated representatives), providers, and multidisciplinary care team to assess the options of care including use of benefits and community resources.Update care plan to include progress towards achieving established goals and self-management activities.Coordinate necessary referrals and authorizations pertinent to patient care and well-being.Utilize developed systems, processes, and initiatives to engage patients in relevant social activities necessary to promote wellness and care at the right place and time.Facilitate member adoption of strategies to promote physician recommended behavior changes.Identify and utilize cultural and community resources and align with the patient's cultural preferences as much as possible.Facilitate the information flow between health representatives and the care team.Coordinate care and communicate with multiple providers, internal and external to the practice.Act as a resource for both clinical and non-clinical staff [i.e., care coordinators, community health works, APPs].Attend required training and collaboration sessions [i.e., learning sessions/ practice team meetings] as scheduled.Provide and facilitate open communication regarding patient status, with physicians and Care at Home Solutions team.Other job-related duties as assigned.Qualifications or Education, Training and ExperienceValid and current LCSW, LMHT, LPCC, LMFT, LCADAC, LICSW, or LMSW CA licensure3-5 years' care management and/or managed care experience in one of the following settings: acute inpatient, rehabilitation, sub-acute, skilled facility, homecare, ambulatory care management, or managed health plan.2-5 years of leadership experience in a care management/managed care setting (preferred)Bilingual Spanish/English strongly preferred.Working Knowledge of the Following Required:Timely and accurate documentation of day-to-day activities in designated technology platform.Adaptable to new technologies and software.Proficiency in EMR system(s), Outlook and data entry experience preferred.Basic PC skills (MS Word/Outlook/PPT/Excel).Knowledge of Federal and State regulations for Medicare and Medicaid and other national and state funded programs.Knowledge of community resources access.Examples of Competencies:Ability to use independent judgment and to manage and impart confidential information.Ability to analyze and solve problems requires details, data and facts that must be analyzed and challenged prior to making decisions.Strong communication, listening interpersonal skills.Ability to clearly communicate medical information to professional practitioners and/or the public.Excellent organization, prioritization, follow up, analytical and time management skills with ability to handle multiple priorities and deadlines.Good interpersonal skills, sense of urgency, being proactive and ownership for one's work.Dependable, with strong work ethics and extremely high degree personal integrity.Ability to deal with multiple interruptions on a continual basis that must be met with a friendly exchange with others.Ability to develop and implement new approaches to improve processes, procedures, or the general work environment.Ability to review critical issues, effectively solve problems and create action plans.Physical/Mental Demands and Work EnvironmentThe physical demands described are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Examples of Work EnvironmentWhile performing the duties of this job, the employee is regularly required to walk, bend, sit, talk, lift, or hear. The employee is regularly required to stand, walk, and use hands and arms to operate general office equipment PC, telephone, file cabinets, copier, postage meter, fax machine and printer. The employee may occasionally lift and/or move between 10 and 25 pounds. Specific vision abilities required by this job include close vision and ability to adjust focus. The employee may need to travel to healthcare practices.The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. The noise level in the work environment is usually low to moderate.