Alignment Health is seeking a bilingual Spanish social worker in San Diego, CA to join the Care Anywhere (CAW) team and conduct home visits in Central and Downtown San Diego area (with mileage reimbursement) As a social worker, you will assess and evaluate members' needs and requirements to achieve and / or maintain their health. You will be providing field, virtual, and telephone visits. You will guide members and their families toward and facilitate interaction with resources appropriate for their care and well-being. You will also work in collaboration 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.
Must be willing to drive to member's homes in San Diego, CA (4) days / week, and conduct (4) home visits per day. (generous mileage reimbursement provided from the time you leave your home to the time you return home)
Must be willing to work remotely (1) day / week.
Participate in paid training (in-field and telephonic shadowing)
Company will provide the equipment.
Responsibilities:
Conduct telephonic and face to face social work outreach to assigned members to assess health, environment, mental health, nutrition, functionality, decline, and psycho-social areas of concerns by conducting a Social Work assessment.
In response to assessments, coach and problem solve with member to identify and address specific goal(s) to support health and behavior change.
Document social work interventions and goals in the EMR, adhering to the departments documentation requirement of submitting face to face field visit documentation within (2) business days of seeing the member. Document all telephonic and virtual visits into the medical record the same day care is provided.
Promote the value of health care advanced directive and documents discussion of member preferences.
Chart member encounters in a thorough and timely manner.
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
Collaborate with other members of the interdisciplinary team.
Charts member's treatments and progress in accordance with state regulations and department procedures.
Make referrals to case manager, as appropriate, and / or refer member's family to community support services and resources.
Provide home assessment to high-risk members and develop an individual care plan
Seek to understand the clinical program design, program monitoring and reporting to best serve members and implement the model of care, will
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.
Assess 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 assessments 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. Participate 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.
Provide crisis intervention services when indicated.
Respond independently, and with various media, to appropriate community requests. Take initiative to seek out opportunities to present programs to meet the needs of patients / members and their families.
Consult with hospitals and plan in the coordination of care regarding the mental health of members. Develop and maintain working relationships with community resources. Coordinate with physicians, and representatives of their service disciplines for the benefit of the member and their families. Take initiative in identifying and assessing 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.
Required Skills and Experience:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Minimum (5) years' experience in care management, medical social work, hospice social work, home health, assessment, long term member / patient care management or community-based resource delivery.
Able to interact effectively with multi-disciplinary team members.
Experience working with vulnerable adults or older adult population.
Able to understand current and potential needs of members to take appropriate action to support member in health and well-being changes.
Able to build trust in partnership with member / client / patient.
Basic knowledge of complex care management and care management principles.
Experience with motivational interviewing-Ability to apply Motivational Interviewing and an Appreciative Inquiry.
Master's degree in social work (MSW) required from an accredited school of social work by the Council on Social Work Education
Unrestricted California Social Work License (LCSW) in good standing preferred.
Bilingual English and Spanish depending on market population needs highly preferred.
Drive to conduct member visits to member's home, skilled nursing facilities (SNF), hospital, board and care, and / or assisted living facilities.
Intermediate to advanced computer skills and experience with Microsoft Word and Outlook.
Able to use a variety of electronic information applications / software programs.
Demonstrated skill in problem solving.
Able to communicate clearly and professionally in both written and oral communication.
Work Environment:
The work environment characteristics described here are representative of those employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Essential Physical Functions:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
The employee frequently lifts and / or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.
