Care Manager Social Worker

This is FT, hybrid- some remote/ office and community based. The Care Manager provides case management services for a caseload of 17-22 Community Living Fund clients who are older adults and adults with disabilities. Responsible for the assessment of clients with multiple medical and psychosocial needs. Plans for and monitors services and interventions ensuring provision of quality care.

RESPONSIBILITIES:

• Conducts comprehensive assessments and on-going re-assessments of the client and including psychosocial, physical and mental health, environmental and spiritual needs.
• Writes comprehensive assessments. Based on assessment information with the client develops and initiates the Community Living Plan, which is client-centered, comprehensive and consistent with program guidelines and policies and procedures.
• 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 a good knowledge of Medicare, Medi-Cal, and other entitlement programs.
• Establishes and maintains a care management relationship with clients and their significant others 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 care plan on an ongoing basis.
• Documents via progress notes all case management activity regarding identified problems within 24-48 hours, adding any new problems to the care plan, as needed.
• Maintains required paperwork and follows a clear, concise, and consistent system of charting to allow for continuity of care.
• 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 significant others 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.
• Working closely with the team, continuously evaluates the clients’ ability to remain safely at home; coordinates placement as appropriate, according to Community Living Fund guidelines.
• In collaboration with the client, caregiver, and involved services, terminates clients when appropriate. Documents the process as required.
• Participates in data collection, as required.
• Participates in and promotes ongoing efforts towards continuous Quality Improvement.
• Attends and actively participates in team and program meetings, activities and problem-solving endeavors; contributes to open lines of communication within the team.
• Utilizes strong collaborative skills with the team members, leadership and community partners offering a constructive and joint approach especially in situations of conflict.
• Utilizes supervision appropriately; maintaining open lines of communication and providing updates on caseload activity.
• Establishes and cultivates mutually respectful and inclusive relationships with clients, staff members, colleagues and community partners.
• Provides culturally responsive services to support clients’ engagement, understands how trauma and other psychosocial factors might influence clients’ participation in social services and care
• Actively assesses and responds to a variety of situations that may include crisis intervention and conflict resolution.
• Actively incorporates the ethical and legal standards of the National Association of Social Workers into all aspects of interactions with others.
• Understands and applies the regulatory and procedural requirements of Community Living Fund as well as the policies and procedures of the Institute on Aging.
• Attends continuing education classes and/or inservice 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.
• All other reasonably related responsibilities as assigned.

Qualifications:
-MSW, MS, MA
-1 year of experience working with older adults