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 lowest access to resources in our community.
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 accessibility 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, safety planning.
- Practices a harm reduction, strengths-based, and informed consent approach.
- Participates and assists in 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 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.
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 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.
- 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.
- 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 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 advance degree preferred.
- Two years of experience in a similar role; or an equivalent combination of education and experience.
- Experience with eligibility for public benefits such as Medi-Cal, Medicare, Social Security, CalFresh, Unemployment, and State Disability benefits is preferred.
- Bi-lingual competency in Spanish or Hmong preferred.
ADDITIONAL RESPONSIBILITIES: In addition to meeting the standards and responsibilities of the Social Work Case Manager, the Social Work Case Manager – Unhoused Services (SWCM-MHS) works in conjunction with Open Door’s Mobile Health Services (MHS) Team, consisting of MDs, PAs, NPs, SUD counselors, BH and psychiatric support, and clinical and clerical support. The MHS team works from a mobile clinic van to access patients where they live in various locations in the greater Eureka-Arcata areas. The SWCM-MHS provides patient assistance to those who are experiencing acute or chronic houselessness by acting as a patient advocate and guide within the context of mobile heath operations and the health goals set by the patient in collaboration with primary medical and behavioral health care providers. The SWCM- MHS assists patients to navigate health care access as well as access to other available services and benefits, including community and governmental programs, maintains knowledge of and relationships with community agencies and resources, and facilitates patient referrals as necessary. This position requires a hardworking individual who is patient, caring, and community-minded. Experience and familiarity with local community resources is strongly preferred. Open Door is looking for a committed and knowledgeable individual who is willing and able to work with diverse patients on the streets of our community and in various weather conditions. Bachelor’s degree in social work, psychology, or human services required; M.S.W. or related advanced degree preferred. Under supervision of the Supervising Case Manager and Site Director, the SWCM-MHS will identify and assess patients who have been recommended for this program by their interdisciplinary care team.
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, forms.
- Ability to remain stationary for extended periods.
- Ability to lift, carry, or otherwise move up to 25 pounds.
- Ability to use 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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