Care Management Social Worker
1 week ago
We are seeking a skilled Care Management Social Worker to join our team at Alameda Health System. As a Care Management 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/or 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, recording 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, and revising the care plan when appropriate.
- 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.
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.
Required Education: Master's degree in social work/welfare issued by a school accredited by the Counsel of Social Work Education.
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