Medical social worker - home care | San Jose, CA

Detailed Information

  • Location: San Jose, CA

with a multi-disciplinary team, employing a variety of strategies, and techniques to enable a member to manage their physical, environmental and psycho-social health issues. Conduct telephonic and face to face Social Work outreach to assigned members to backss health, environment, mental health, nutrition, functionality, decline, and psycho-social areas of concerns by conducting a Social Work backssment.

In response to backssments, 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. 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 Makes referrals to case manager, as appropriate, and/or refers member's family to community support services and resources. Provide home backssment

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 inpatient and outpatient service locations in accordance with Social Work standards of practice.

backss 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 backssments 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. Respond independently, and with various media, to appropriate community requests. Consults with hospitals and plan in the coordination of care regarding the mental health of members.

Develop and maintain working relationships with community resources. Take initiative in identifying and backssing 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.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 5 years of experience in care management, Medical Social Work, Hospice Social Work, Home Health, backssment, long term member/patient care management or community-based resource delivery. 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. Master's Degree in Social Work (MSW) required from an accredited School of Social Work by the Council on Social Work Education Preferred unrestricted California Social Work License (LCSW) in good standing Preferred Bilingual in Spanish depending on market population needs Work requires driving to field visits where Member is. Intermediate to advanced computer skills and experience with Microsoft Word and Outlook email system. Ability to use a variety of electronic information applications/software programs.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. For more details: jobs-search. org/legal_san-jose-c426441/medical-social-worker-home-care-san-jose_i1959781665

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