Care Manager I or II
May 11, 2023 |
The Social Worker – Case Manager II provides intensive case management services for a caseload of 15-20 high risk adults and seniors in the community in their homes. Responsible for the assessment of clients with multiple medical and psychosocial needs. Plans for and monitors services and interventions ensuring provision of quality care. Clients are adults whom are medically fragile, physically compromised with mental health or cognitive challenges. Car is required, mileage is reimbursed. Clients are located anywhere from Daly City to San Mateo.
- Conducts comprehensive assessments and on-going re-assessments of the client including psychosocial, physical and mental health, environmental and spiritual needs.
- Writes comprehensive assessments.
- Conducts home visits, acute hospital & skilled nursing facility visits, as well as escorts clients to medical and other appointments as clinically indicated.
- Identifies, arranges for, and monitors appropriate community services based on a good knowledge of Medicare, Medi-Cal, and other entitlement programs.
- Establishes and maintains a care management relationship with clients and their informal support network as appropriate, offering respect, dignity and support. Provides crisis intervention, advocacy, problem solving and therapeutic interventions.
- Meets with clients at least monthly, and more often as clinically indicated. Reviews and modifies their Community Living Plan on an ongoing basis.
- Documents via progress notes all case management activity regarding identified problems within 24-48 hours
- Ongoing evaluation for client Purchase of Service needs and follow-up to determine if services have been provided in a timely manner.
- Educates clients and informal support network about resources.
- 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.
- Monitors the quantity and quality of the services provided by other involved providers.
- Working closely with the team, continuously evaluates the clients’ ability to remain safely at home; coordinates placement as appropriate, according to program guidelines.
- In collaboration with the client, caregiver, and involved services, terminates clients when appropriate. Documents the process as required.
- Continuous Quality Improvement.
- MSW degree preferred but BSW degree at a minimum
- One year working with older adults and/or adults with disabilities