GENERAL SUMMARY: A Social Work Case Manager (SWCM) at Open Door Community Health Centers (ODCHC) provides integrated, supportive, and enabling services to health center patients. The SWCM collaborates with an interdisciplinary care team to ensure continuity of care and assist patients in accessing services and utilizing resources to support their medical, psychological, and socioeconomic needs. The SWCM identifies and addresses a variety of non-clinical social determinants of health (SDoH) to promote positive health outcomes and reduce health inequities. The SWCM is dedicated to serving marginalized or otherwise underserved populations with the lowest access to resources in our community.
SUMMARY PERINATAL-SPECIFIC
In addition to meeting the standards and responsibilities of the Social Work Case Manager, the Social Work Case Manager-Perinatal works with all Open Door staff providing prenatal services and postpartum care at multiple facilities. Staff includes MDs, CNMs, RNs, Doulas, and clinical support. The SWCM-Perinatal is based out of Redwood Community Health Center and travels to various clinic locations as needed to provide resource assistance and services to pregnant and postpartum patients and their immediate families. The SWCM-Perinatal works collaboratively with the SWCM-Pediatrics to transition CM services for the infant at an appropriate time and on an individual basis. The SWCM-Perinatal will work closely with the Supervising Case Manager to ensure quality of care.
In addition to meeting the standards and responsibilities of the Social Work Case Manager, the Social Work Case Manager—Perinatal has a strong understanding of the biological, psychological, societal, and cultural factors related to pregnancy, labor and delivery, and postpartum aspects of Women’s Health, and initial stages of neonatal health, and the ability to provide emotional support and assistance in navigating crises.
Upon referral from a provider, the SWCM-Perinatal will coordinate with pregnant and/or postpartum patients and their families to develop, implement, and monitor effective treatment plans. The SWCM will assess the biopsychosocial needs of each patient (and family) and their coping and adaptive abilities, formal and informal support systems, as well as identify individual barriers and areas of needs, and strategize with the patient and health care team to develop a plan to overcome such barriers.
The SWCM—Perinatal will meet regularly with the clients to assist them in fulfilling recommendations for their plan of care including, but not limited to, explanation of special instructions, aid in problem resolution and decision making, providing resources and education to other ODCHC Case Managers and interdisciplinary care team members as needed, and performing other duties and responsibilities as identified and assigned by the Supervising Case Manager.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Assists patients in navigating the social determinants of health (SDoH) in order to provide effective interventions, improve health outcomes, and increase access to resources.
- Maintains knowledge of and effective relationships with community resources, benefit programs, and social service providers. Provides direct assistance with eligibility, referral, documentation, navigation, education, enrollment, and follow-up when necessary.
- Assesses the biopsychosocial needs of each patient. Identifies individual barriers, strengths, and areas of need to formulate an individualized effective case management treatment plan and implementation strategies. Collaborates with patient and care teams to develop a plan to overcome obstacles and find solutions.
- Meets regularly with patients. Utilizes proactive and flexible delivery of evidence-based approaches. Employs strategies to engage patients and families in achieving goals and optimizing health.
- Manages complex cases and ensures services across the continuum of care.
- Identifies and facilitates appropriate referrals to alcohol and drug programs, disability services, employment & training programs, mental health providers, housing services, family resources transportation, long-term care planning, social services, resources for food and financial security, county, state, and federal programs, and other community sources of support based on patient need.
- Knowledgeable in de-escalation techniques, crisis intervention, trauma response, and safety planning.
- Practices a harm reduction, strengths-based, and informed consent approach.
- Participates and assists in the facilitation of peer support and educational groups within internal case management, behavioral health, and substance use programs as directed.
- Liaises with internal and external programs or agencies to promote interagency collaboration.
- Participates in case conferences with primary care teams, behavioral health clinicians, discipline-specific supervisors and other case managers for feedback, education, and support. Enables consultation with interdisciplinary providers such as psychiatry, medication-assisted treatment, intensive outpatient nurse case management, and other embedded programs as needed.
- Meets standards for referrals, tracking, and reporting set by the department. Participates in quality improvement and risk management activities.
- Actively participates in program development, planning, implementation, and evaluation.
- Monitors systemic barriers and access to care issues. Communicates recommendations to supervisor and clinic leadership on areas for future attention.
- Contributes positively to the efficiency, accessibility, productivity, quality, safety, compassion, and professionalism of the work setting.
- Other duties and responsibilities as identified and assigned by supervisor(s).
QUALIFICATIONS AND EXPECTATIONS:
- Strong interpersonal skills and the ability to establish constructive professional working relationships among a diverse workforce.
- Effective active listening, motivational interviewing, emotional intelligence, cultural humility, and critical thinking skills to engage a diverse population of patients and families.
- Ability to advocate for patients, encourage independence, and assist in the development of skills to manage challenges and make healthy decisions to support mutual goals. Solutions-oriented with a creative problem-solving approach.
- Knowledgeable of the effects of trauma and how it can impact families experiencing poverty, food insecurity, substance use problems, housing insecurity, and other SDoH. Familiar with evidence-based practices and patient-centered care such as trauma-informed, resilience-oriented framework.
- Works well under pressure with minimal supervision. Excellent time management and organizational skills. Flexible and able to handle multiple cases and competing demands simultaneously.
- Functions well within an interdisciplinary team. Acts as a contributing member of the care team offering a collaborative approach to treatment. Keeps team informed about progress towards goals and any changes to the care plan.
- Ability to handle difficult or confrontational situations in a calm, consistent, and equitable manner.
- Detail oriented and patient. Ability to accurately write comprehensive chart notes as well as routine correspondence. Able to complete extensive forms and paper applications.
- Ability to effectively represent ODCHC’s interests in the community and maintain effective working relationships among co-workers, public, private, and professional groups.
- Strong computer skills with specific aptitude in Microsoft Office Suite and/or Electronic Medical Records (EMR).
- Adheres to the National Association of Social Work Code of Ethics: Service, Integrity, Social Justice, Competence, Importance of Human Relationships, Dignity, and Worth of the Person.
- Adheres to ODCHC’s policies and procedures.
EDUCATION AND EXPERIENCE:
- Bachelor’s degree in social service or health-related field or an equivalent combination of education and experience required; Masters’ or related advanced degree preferred.
- Demonstrated experience working with intersectional marginalized populations, including persons diagnosed with mental illness, a disability, seniors, houseless, and/or substance-dependent patients.
- Knowledge of local community resources and agencies providing social services.
- Experience with eligibility for public benefits such as Medi-Cal, Medicare, Social Security, CalFresh, Unemployment, and State Disability benefits is preferred.
- Bilingual competency in Spanish or Hmong preferred.
SUPERVISORY RESPONSIBILITIES: None.
SUPERVISION AND SUPPORT: The Social Work Case Manager reports directly to their assigned Supervising Social Work Case Manager under direct supervision of the Health Resources Manager. The SWCM works closely with the Administrative Site Director, clinic leadership, and other ODCHC departments.
PHYSICAL REQUIREMENTS: This is largely an office-based position. The physical requirements described are representative of those needed to successfully perform the essential duties of the position. Reasonable accommodation will be made to allow otherwise qualified candidates to perform these functions.
- Ability to communicate via telephone, video, and/or in person.
- Vision adequate to read documents, computer screens, and forms.
- Ability to remain stationary for extended periods.
- Ability to lift, carry, or otherwise move up to 25 pounds.
- Ability to use a computer’s keyboard and view computer screens for extended periods.
- Ability to travel locally and long-distance as needed.
- Ability to move around offices and clinics as needed.
Location: On Site
Open Door is an equal opportunity employer. All applicants will be considered for employment regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, medical condition, age, pregnancy, marital status, ancestry, veteran or disability status.
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