Vivo HealthStaff is conducting a search for a Medical Social Worker for a health plan in Chula Vista, California.

General Duties/Responsibilities:

(May include but are not limited to)

Conduct telephonic Social Work outreach to assigned members to assess health, environment, mental health, nutrition, functionality, decline, and psycho-social areas of concerns by conducting a Social Work assessment.
In response to assessments, coach and problem solve with member to identify and address specific goal(s) to support health and behavior change.
Timely documents Social Work Interventions and goals in the EMR. Adheres to the departments documentation requirement of submitting face to face field visit documentation within 2 business days of seeing the Member. Documents all telephonic and virtual visits into the medical record the same day care is provided.
Promotes the value of Health Care Advanced Directive and documents discussion of member preferences.
Charts thoroughly and timely on all Member encounters.
Provide appropriate interventions to optimize health and well-being. Interventions may include education, the coordination of community- based support services, supportive counseling for mental health conditions, care navigation, advanced care and end of life planning
Collaborate with other members of the interdisciplinary team.
Charts member's treatments and progress in accordance with state regulations and department procedures.
Makes referrals to case manager, as appropriate, and/or refers member's family to community support services and resources.
Provide home assessment to high-risk members and develop an individual care plan
To better serve members and implement the model of care, will understand the clinical program design, program monitoring and reporting.
Perform a full range of clinical Social Worker procedures in accordance with clinical privileges granted by the Plan and based in accordance with Social Work standards of practice.
Practice as an interdependent member of the health team and provide important components of primary health care through direct Social Work Services, consultation, collaboration, referral, teaching, and advocacy.
Provide direct and indirect services to both inpatients and outpatients in accordance with Social Work standards of practice.
Assess and treat outpatients in individual and family modalities exercising mature professional judgment and using a wide range of social work skills to include individual and family counseling to assist patients and their families in dealing with chronic and acute diseases/injuries.
Conduct psychosocial assessments to determine patient needs and resources (both family support and community support). Provide counseling to patient and family in matters directly related to patient’s limitation, adjustment to medical condition, and ongoing treatment. Participates with Nurses and Physicians in the implementation of discharge plans, follow-up care, and transfers to other health care facilities (e.g., nursing homes, rehabilitation hospitals, etc.)
Plan and maintain referral and coordination services of services with other agencies to provide optimal patient care.
Provide consultation services to medical, nursing, and ancillary hospital staff regarding psychosocial issues, discharge plans, and follow-up care for patients and families.
Provide crisis intervention services when indicated.
Respond independently, and with various media, to appropriate community requests. Take the initiative in seeking out opportunities to present programs to meet the needs of patients/members and their families.
Consults with hospitals and plan in the coordination of care regarding the mental health of members. Develop and maintain working relationships with community resources. Coordinate with physicians, and representatives of their service disciplines for the benefit of the member and their families. Take initiative in identifying and assessing the needs of the community and organize responses to address those needs.
Act as a human services agent, using clinical judgment and knowledge of area resources to provide information and referrals to patients and other care providers.
Interface with the RN Case Manager(s) and the Interdisciplinary Team (IDT) in the development and implementation of Social Work interventions.
Integrate Social Work case management and nurse case management as a team.

Minimum Requirements:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Minimum Experience:

5 years of experience in care management, Medical Social Work, Hospice Social Work, Home Health, assessment, long term member/patient care management or community-based resource delivery.
Ability to interact effectively with multi-disciplinary team members.
Previous work with vulnerable adults or older adult population.
Skill to understand current and potential needs of members to take appropriate action to support member in health and well-being changes.
Skill in building trust in partnership with member/client/patient.
Basic knowledge of complex care management and care management principles.
Experience with motivational interviewing-Ability to apply Motivational Interviewing and an Appreciative Inquiry.
Education/Licensure:
1. Master’s Degree in Social Work (MSW) required from an accredited School of Social Work by the Council on Social Work Education
2. Unrestricted California Social Work License (LCSW) in good standing
3. Bilingual in Spanish Preferred depending on market population needs

Other:

1. Work requires driving to field visits where Member is.
2. Intermediate to advanced computer skills and experience with Microsoft Word and Excel.
3. Ability to use a variety of electronic information applications/software programs.
4. Demonstrated skill in problem solving.
5. Ability to communicate clearly and professionally in both written and oral communication.

Work Environment:

1. The work environment characteristics described here are representative of those employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.