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Care Manager Social Worker
1 month ago
Job Summary:
We are seeking a skilled Care Manager Social Worker to join our team at Alameda Health System. As a Care Manager Social Worker, you will play a critical role in restoring patients to optimum health and social adjustment, while facilitating a positive impact on the hospital transition of care.
Key Responsibilities:
- Collaborate with the Care Transition team and Health Advocates to ensure timely follow-up appointments and confirm prior to discharge that complex patients are appropriately linked to community services.
- Coordinate patient care activities with other members of the healthcare team, the patient, the patient's representatives, and community partners, making referrals as appropriate.
- Effectively intervene in suspected abuse/neglect cases and in complex or high-risk situations as requested, identifying and intervening with high-risk behaviors, responding to traumas.
- Identify and mobilize patients and family strengths to optimize use of healthcare and community resources, guiding/assisting in securing needed post-discharge services, and providing consultation and education to team members regarding patient/family (psychosocial and discharge planning) issues and community resources.
- Identify potential problems, prevent, and resolve variances to the care management plan, assessing and coordinating family and community resources to meet identified needs to support the discharge plan.
- Intervene with patients and patient's representatives regarding emotional, behavioral, and financial barriers to current illness and/or disability.
- Lead patient-centered conferences to meet needs and desires of the patients.
- Maintain patient records, including patient assessments, plans, interventions, patient/family involvement, outside agency communications, and interdisciplinary contacts.
- Participate in discharge planning activities, effectively identifying and intervening with high-risk discharge planning issues with psychosocial complexity, assisting Care Management Nurses with discharge planning efforts as requested.
- Perform psychosocial assessment interviews with patients and/or families and record this assessment in the patient's medical record, assessing patient's level of functioning, environment, appropriateness, and adequacy of support system related to illness and ability to cope.
- Provide patient advocacy, including primary responsibility for initiating processes regarding capacity determinations, grief counseling, and conservatorship/guardianship, taking advocacy leadership role regarding adoption/surrogacy cases.
- Refer and assist patients/families in applying for appropriate financial programs (CCS, SDI, SSI, SSD, private pensions) and legal instruments as needed.
- Screen for any barriers to care such as substance abuse, neglect, financial limitations, or housing.
- Serve as a resource and provide counseling and treatment related to palliative care or end-of-life planning.
Requirements:
Education: Master's degree in social work/welfare issued by a school accredited by the Counsel of Social Work Education.
Preferred Education: Master's degree in social work/welfare issued by a school accredited by the Counsel of Social Work Education with Required Experience: Two years of Social work or Case Management experience in an acute setting or protective services.
Preferred Licenses/Certifications: Active certification in Case Management (ACM or CCMC), Current and valid license as a Clinical Social Worker issued by the State of California Board of Behavior Science Examiners. Bilingual preferred.
Work Environment: San Leandro Hospital, SLH Social Services, Part-time, Day, Care Management, FTE: 0.8
