Title: Medical Social Worker
Department: Home Care & Hospice
FLSA Status: Non-Exempt
Reports To: Chief Compliance Officer / Administrator
Summary: Provides case management services for a caseload of 17-22 clients. Responsible for the assessment of clients with multiple medical and psychosocial problems. Plans for and monitors services and interventions ensuring provision of quality care.
1. Conducts comprehensive assessments and on-going re-assessments of the client and including psychosocial, physical and mental health, environmental and spiritual needs.
2. Writes comprehensive assessments. Based on assessment information with the client develops and initiates the Care Plan, which is client-centered, comprehensive and consistent with agency guidelines as outlined in the Policy and Procedure Manual.
3. Identifies arranges for and monitors appropriate community services base on good knowledge of Medicare, Medi-Cal, and other entitlement programs.
4. Establishes and maintains a care management relationship with clients and their significant others as appropriate, offering respect, dignity and support. Provides crisis intervention, advocacy, and problem solving and therapeutic interventions.
5. Meets with clients at least monthly, and more often as needed. Maintains court settlement agreement meeting schedule for discharges when appropriate. Reviews and modifies their Care Plan on an ongoing basis.
6. Documents via progress notes all case management activity regarding identified problems within 24 hours, adding any new problems to the service plan, as needed.
7. Maintains required paperwork and follows a clear, concise, and consistent system of charting to allow for continuity of care.
8. Ongoing evaluation for client Purchase-of-Services needs and follow-up to determine if services have been provided in a timely manner.
9. Educates clients and significant others about resources and when possible, trains them to provide their own case management.
10. Establishes and maintains open and effective communication with community providers, including physicians and other health care and social service workers. Provides appropriate information on all significant aspects of individual client care and program operations, while maintaining necessary confidentiality.
11. Monitors the quantity and quality of the services provided by other involved providers.
12. Working closely with the team, continuously evaluates the clients’ ability to remain safely at home; coordinates placement as appropriate, according to agency guidelines.
13. In collaboration with the client, caregiver, and involved services, terminates clients when appropriate. Documents the process as required.
14. Participates in research studies and data collection, as required.
15. Participates in and promotes ongoing efforts towards Continuous Quality Improvement.
16. Attends and actively participates in team and program meetings, activities and problem-solving endeavors; contributes to open lines of communication within the team.
17. Utilizes supervision appropriately; maintaining open lines of communication and providing updates on caseload activity.
18. Actively incorporates the ethical standards of the National Association of Social Workers into all aspects of interactions with others.
19. Understands and applies the regulatory and procedural requirements of agency as well as the policies and procedures of the local, state and federal.
20. Attends continuing education classes and/or in-service training to increase knowledge, skills and attitudes related to case management, gerontology, family and community systems and other areas relevant to the Community Living Fund client population.
21. All other reasonably related responsibilities as assigned.
1. Master degree in Social Work required.
2. One year’s experience working with disabled adults and/or frail elderly required.
3. Experience with and understanding of the medical and psychosocial problems of functionally impaired adults and the frail elderly.
4. Bilingual highly preferred; English plus Cantonese and / or Mandarin.
5. Exceptional communication and presentation skills relating to the frail elderly, functionally impaired adults, their support systems and teams of health professionals.
6. Demonstrates case management skills and experience in the community health care delivery system.
7. Detail oriented with good problem solving skills and the ability to prioritize multiple tasks.
8. Computer literacy required.
9. Ability to lift up to 25 lbs.
10. Ability to reach, bend, and walk.
11. Five finger manipulation.
12. Ability to speak and write English clearly.
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