Care Manager I

Institute on Aging•San Bernadino, CA

About The Position

IOA is on the forefront of revolutionary healthcare models, reshaping the way people can age in place. Our innovative models transform lives, enhance communities, and save healthcare systems millions of dollars. Rather than focusing on archaic outdated design, we strive to consistently question the “status-quo” and create new and more innovative ways to help aging adults and adults with disabilities maintain their quality of life. With over 23 programs, we offer multiple ways to aid seniors maintain their health, well-being, independence and participation in the community, fulfilling our mission. Enhanced Care Management services are offered through CalAIM and Institute on Aging (IOA) for adults transitioning from nursing facilities, adults living in the community who wish to remain home, adults living with mental health or substance use, and adults experiencing homelessness. We also provide community support services for those seeking housing, and those who need housing adapted to meet their physical needs.

Requirements

B.A or B.S in Social Work or related field required
One year’s experience working with disabled adults and/or frail elderly required.
Experience with and understanding of the medical and psychosocial problems of functionally impaired adults and the frail elderly.
Exceptional communication and presentation skills relating to the frail elderly, functionally impaired adults, their support systems and teams of health professionals.
Demonstrates case management skills and experience in the community health care delivery system.
Detail oriented with good problem-solving skills and the ability to prioritize multiple tasks.
Computer literacy required.
Ability to lift up to 25 lbs.
Ability to reach, bend, and walk
Five finger manipulation
Ability to speak and write English clearly

Nice To Haves

Bilingual highly preferred; English plus Cantonese and / or Mandarin and/or Spanish.

Responsibilities

Conducts comprehensive assessments and on-going re-assessments of the residents 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 client-centered Community Living Plan.
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 needed.
Reviews and modifies their Community Living Plan on an ongoing basis.
Documents via progress notes all case management activity regarding identified problems within 24 hours, adding any new problems to the service plan, as needed.
Maintains required paperwork and follows a clear, concise, and consistent system of charting to allow for continuity of care.
Educates clients and significant others about resources and when possible, trains them to provide their own case management.
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.
In collaboration with the client, caregiver, and involved services, terminates clients when appropriate.
Documents the process as required.
Participates in research studies and data collection, as required.
Participates in and promotes ongoing efforts towards Continuous Quality Improvement.
Attends and actively participates in IOA and Santa Clara Methodist Retirement Foundation team and program meetings, activities and problem-solving endeavors; contributes to open lines of communication within the teams.
Utilizes supervision appropriately, maintaining open lines of communication and providing updates on caseload activity.
Actively incorporates the ethical 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 Services as well as the policies and procedures of the Institute on Aging.
Attends continuing education classes and/or in-service training to increase knowledge, skills and attitudes related to case management, gerontology, family and community systems and other areas relevant to the client population.
All other reasonably related responsibilities as assigned.