Medical Social Worker- Bakersfield 1.1

Duties and Responsibilities

• Effectively manage and maintain a caseload of ECM members with higher behavioral and social acuity/ risk tier levels.
• Conduct a comprehensive assessment to develop a comprehensive, individualized,person-centered care plan with input from the member (and/or their parent, caregiver, guardian) to prioritize, address, and communicate strengths, risks, needs, and goals.
• Supports members with behavioral health conditions, with particular attention to members with SMI and/or SUD needs, through brief interventions, behavioral activation strategies, and linkages to community resources.
• Provide formal and informal training and support for ECM members on behavioral health conditions, including treatments and evidence-based for treatment.
• Tracks medical and behavioral health outcome measures in the web-based care management platform or equivalent platform.
• Responsible for building and maintaining a positive working relationship with Providers, including, but not limited to, communication via in-person, over the phone, and through digital means such as email and fax.
• Responsible for engaging with members, both in-person and on the phone, in a manner that utilizes evidence-based approaches (such as Motivational Interviewing) that promotes collaboration between the member and his or her medical/behavioral team, as well as to increase the member’s sense of control over their whole health.
• Conduct in-person outreach and enrollment in community settings such as shelter, navigation sites, schools, substance use centers, churches—etc.
• Responsible for brief crisis interventions and warm hand-offs to local crisis resources as needed to address behavioral health needs.
• Engage with each member (and/or their parent, caregiver, guardian) authorized to receive ECM primarily through in-person contact and provide culturally appropriate and accessible communication.
• Identify necessary clinical and non-clinical resources that may be needed to appropriately assess member health status and gaps in care and may be needed to inform the development of an individualized Care Management Plan.
• Ensure member’s care plan, incorporate identified needs and strategies to address needs, including, but not limited to, physical and developmental health, mental health, dementia, SUD, LTSS, oral health, palliative care, necessary community-based and social services, and housing.
• Ensure the member is reassessed at a frequency appropriate for the member’s individual progress or changes in needs and/or as identified in the Care Management Plan.
• Ensure the Care Management Plan is reviewed, maintained, and updated under appropriate clinical oversight. Perform care coordination of care services necessary to implement the care plan.
• Gather information, present, and participate in Interdisciplinary Care Team (ICT) meetings.
• Organize member care activities, as laid out in the care plan; sharing information with those involved as part of the member’s multi-disciplinary care team; and implementing activities identified in the care plan.
• Provide support to engage the member in their treatment, including coordination for medication review and/or reconciliation, scheduling appointments, providing appointment reminders, coordinating transportation, accompaniment to critical appointments, and identifying and helping to address other barriers to member engagement in treatment.
• Communicate the member’s needs and preferences in a timely manner to the member’s multi-disciplinary care team.
• Ensure regular contact with the member (and/or their parent, caregiver, guardian) when appropriate, consistent with the care plan and to monitor the member’s conditions, health status, care planning, medications usages and side effects.
• Ensure care is continuous and integrated among all service Providers and referring to and following up with primary care, physical and developmental health, mental health, SUD treatment, LTSS, oral health, palliative care, and necessary community-based and social services, including housing, as needed.
• Provide services, such as coaching, to encourage and support members to make lifestyle choices based on healthy behavior, with the goal of promoting effective self-management skills.
• Support members in strengthening skills that enable them to identify and access resources to assist them in managing their conditions and preventing other chronic conditions.
• Use evidence-based practices, such as motivational interviewing, to engage and help the member participate in and manage their care.
• Provide transitional care services, including completion of discharge risk assessment and coordinating any follow up provider appointments and support services to facilitate safe and appropriate transitions from one setting or level of care to another.
• Coordinate medication review/reconciliation and provide adherence support and referral to appropriate services.
• Determine appropriate services to meet the needs of members, including services that address SDOH needs, including housing, and services offered by Community Supports.
• Coordinate and refer members to available community resources and follow up with members (and/or parent, caregiver, guardian) to ensure services were rendered (i.e., “closed loop referrals”).
• Work collaboratively with other staff (LVNs, MAs, MSW, and non-clinical ECM staff) to provide quality assurance review of clinical documentation and implementation of ECM activities, including documentation of comprehensive assessments, transition of care follow-up, medication reconciliation, and development and implementation of care plans.
• Ensures documentation is accurate and in compliance with regulatory requirements and accreditation standards.
• May support the leadership team in ensuring compliance with regulatory requirements.
• Attend mandatory departmental and staff meetings.
• Assist with training and orientation of new staff.
• Other duties as assigned.

Qualifications

• Possession of a master’s degree from an accredited college or university with a major in Social Work, Psychology, Counseling, or a closely related behavioral science field.
• Experience: Two years of full-time experience providing counseling and/or social work services to medical patients.
• Substitution for Education and Experience: Possession of a Baccalaureate Degree from an accredited college or university with a major in Social Work, Psychology, Counseling, or a closely related behavioral science field and either: a) two years of full-time or its equivalent experience as a Medical Social Worker I or b) three years of full-time or its equivalent experience providing counseling and/or social work services to medical patients.
• Familiarity with Managed Care and discharge planning is preferred.
• Deep understanding and knowledge of mental health and substance use conditions, including both acute and chronic management of symptoms.
• Knowledgeable and skilled in evidenced based communication such as Motivational Interviewing, or similar empathy-based communication strategies.
• Understanding of and sensitivity to multi-cultural community.
• Awareness of the impact of unmitigated bias and judgement on health; commitment to addressing both.
• Understanding and knowledge of self-management philosophies and practices, especially as they relate to chronic medical conditions.
• Able to sufficiently engage members and providers in person or on the phone.
• Proficiency in data interpretation and demonstrates the ability to learn new information systems and software programs.
• Required attention to detail, analytical thinking skills, excellent technical, interpersonal, and oral communication skills.
• Must be able to work as a member of a highly autonomous team, executing job duties and as an independent team.
• Experience in but not limited to Medicare and Medi-Cal (CMS) environment preferred.
• Strong organizational and time management skills required.
• Must be able to show compassion, empathy, and be sympathetic with nonjudgmental treatment to patients and family or support teams.
• Must be able to use clinical skills to analyze, review and judge different situations patients face and take the required actions according to regulations and expectations, and ethical guidelines.
• Ability to be flexible and work in a changing environment.
• Willingness to collaborate as part of a team with professionals at all levels to achieve goals and remove barriers to member health.
• Sensitivity to members' social, cultural, language, physical, and financial differences.
• Ability to work with members and influence behavior through negotiation of care goals and support of member self-management.
• Strong problem-solving skills and ability to identify issues and propose solutions.
• Ability to prioritize tasks based on changes in member situations and needs.
• Ability to work independently, organize and prioritize multiple tasks throughout the day.
• Strong attention to detail and ability to be accurate, thorough, and persistent in problem-solving and task completion.
• Excellent verbal and written communication skills, with the ability to communicate effectively with all levels of the organization and members.
• Proficiency in creating professional documents with proper grammar and punctuation.
• Ability to maintain professionalism and adapt to a changing environment.
• Ability to understand and communicate complex health and benefit information.
• Proficient in the use of common office technology, including electronic Case Management systems.
• Reliable in attendance and adherence to work schedule and business dress code.
• Ability to always maintain strict confidentiality.
• Demonstrated experience working with one or more of the ECM populations of focus, including but not limited to: adults and children experiencing homelessness, those with serious mental illness (SMI) or substance use disorders (SUD), high utilizers of healthcare services, adults or children with complex physical, behavioral, or developmental conditions, individuals transitioning from incarceration, children/youth involved in child welfare, or those belonging to the birth equity population.

Other Requirements

• Possession of valid driver’s license
• Proof of state-required auto liability insurance.
• Reliable transportation is required to perform essential duties, including traveling to locate and engage with members in the field or at various locations as needed.

Working Conditions

• This position may be subject to tuberculosis (TB) testing requirements based on job duties and work location. Employees whose roles involve regular contact with members will be required to provide proof of a current negative TB test prior to hire and periodically thereafter, in accordance with organizational policy and applicable public health regulations.