Care Management Social Worker

6 days ago


Emeryville, California, United States Alameda Health System Full time
Job Summary

We are seeking a highly skilled Care Management Social Worker to join our team at Alameda Health System. The successful candidate will be responsible for 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, and make referrals as appropriate.
  • Effectively intervene in suspected abuse/neglect cases and in complex or high-risk situations as requested, and be competent to identify and intervene with high-risk behaviors, responding to traumas.
  • Identify and mobilize patients and family strengths to optimize use of healthcare and community resources, and in coordination with patient and family wishes, guide/assist in securing needed post-discharge services.
  • Identify potential problems, prevent, and/or resolve variances to the care management plan, and assess and coordinate 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 identify and intervene with high-risk discharge planning issues with psychosocial complexity, and assist 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, and take 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
  • Master's degree in social work/welfare issued by a school accredited by the Counsel of Social Work Education.
  • Two years of social work or case management experience in an acute setting or protective services.
  • Active certification in Case Management (ACM or CCMC), and current and valid license as a Clinical Social Worker issued by the State of California Board of Behavior Science Examiners.


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