Social Worker (PHM)- Bakersfield 1.1

Social Worker

The Social Worker is responsible for addressing the clinical and non-clinical needs of members across the Population Health Management (PHM) continuum. The role focuses on supporting members with complex medical, behavioral, and social needs through person-centered care coordination, advocacy, and connection to health and community-based resources. Services may be provided telephonically, virtually, in clinics, or in members' homes and communities, based on member preference and program requirements. The Social Worker provides services and coordination with members to ensure continuity of care across health and social service programs, including community-based resources and long-term services and supports (LTSS). The Social Worker collaborates with an interdisciplinary care team (ICT) that includes case managers, clinicians, community health workers, and other professionals to ensure members receive coordinated, continuous care. The Social Worker supports members in addressing behavioral health and social needs, reducing barriers to care, and connecting to resources that promote wellness, stability, and self-management.

Job Duties and Responsibilities:

• Manage and maintain a caseload of PHM members, with a primary focus on those with behavioral health and social needs, while coordinating with the care team on medical needs as appropriate.
• Conduct comprehensive assessments and develop individualized, person-centered care plans in collaboration with members, caregivers, and providers.
• Support members with behavioral health needs, including serious mental illness (SMI) and/or substance use disorders (SUD) through linkage to appropriate services.
• Provide culturally appropriate education to members and caregivers regarding behavioral health, chronic disease self-management, and community resources.
• Track member outcomes and document all encounters, interventions, and care plan updates in the Case Management (CM) system in compliance with organizational standards.
• Build and maintain collaborative relationships with providers, community agencies, and social service organizations to facilitate referrals and care coordination.
• Engage members using evidence-based approaches such as Motivational Interviewing to promote collaboration, increase member activation, and improve self-management skills.
• Provide brief crisis intervention and warm hand-offs to appropriate resources as needed.
• Support transitional care services by coordinating discharge planning, scheduling post discharge provider or TOC Clinic appointments, reconciling social/behavioral needs, and connecting members to ongoing supports to reduce avoidable readmissions and ER visits.
• Provide navigation and coordination of long-term services and supports (LTSS), ensuring members and caregivers are connected to appropriate programs that promote independence, stability, and quality of life.
• Address members' social determinants of health (SDOH) by identifying needs such as housing, food insecurity, transportation, financial instability, or caregiver support, and facilitating access to community-based resources and services.
• Support members in strengthening skills that enable them to manage their conditions, identify and access needed resources, prevent complications, and maintain independence.
• Ensure care is continuous and integrated among all service providers by coordinating and following up with primary care, behavioral health, substance use treatment, LTSS, oral health, palliative care, and necessary community-based and social services, including housing.
• Ensure closed-loop referrals by confirming that services were received and barriers resolved.
• Participate in Interdisciplinary Care Team (ICT) meetings and case conferences to support care planning and coordination.
• Provide member advocacy by communicating needs, preferences, and goals to care teams in a timely and effective manner.
• Ensure documentation is accurate, timely, and compliant with regulatory standards.
• Attend mandatory departmental and staff meetings and contribute to process improvement initiatives.
• Assist with the training and orientation of new staff.
• Perform other duties as assigned.

Qualifications:

• Bachelor's degree in social work, Psychology, Counseling, or a closely related behavioral science field from an accredited institution required.
• Master's degree in social work, Psychology, Counseling, or a closely related behavioral science field preferred.
• Minimum of 2 years of experience providing counseling, social work, or care coordination services in a healthcare or community setting.
• Familiarity with managed care, population health, and discharge planning preferred.
• Valid CA driver's license, automobile insurance, and reliable transportation for occasional travel to clinics, member residences, or community sites.

Skills and Abilities:

• Strong understanding of mental health and substance use conditions, including acute and chronic management of symptoms.
• Skilled in evidence-based communication strategies such as Motivational Interviewing or other empathy-based approaches.
• Cultural sensitivity, with awareness of how bias and judgment impact health outcomes.
• Knowledge of self-management practices for chronic conditions.
• Strong interpersonal skills with the ability to engage members and providers in person, by phone, and in community settings.
• Analytical and problem-solving skills, with the ability to interpret data, identify issues, and propose solutions.
• Strong organizational and time management skills, with the ability to prioritize tasks, adapt to changing situations, and work independently or collaboratively as part of a team.
• Compassionate, empathetic, and nonjudgmental approach in supporting members and their caregivers.
• Ability to apply sound clinical judgment within ethical and regulatory guidelines.
• Excellent verbal and written communication skills, with the ability to clearly explain complex health and social information.
• Proficiency in Microsoft Office (Word, Excel, Outlook), case management systems, and other office technology.
• Ability to maintain professionalism, reliability, and strict confidentiality at all times.