HCBA Waiver Medical Social Worker

San Ysidro Health•San Diego, CA

13d•$34 - $44

About The Position

Reporting to the HCBA Waiver Manager and serving as a member of the Care Management Team, the Social Worker supports the development and monitoring of plans of treatment for a caseload of Home and Community Based Alternatives (HCBA) Waiver Program participants. The role evaluates services in community settings—including in-home, telehealth, and telephonic—to help ensure the health, safety, and well-being of vulnerable and high-risk populations. Duties include transfer coordination, discharge planning, authorizations for covered services, participant screening, case management, counseling, and referrals. The Social Worker proactively manages the social-service needs of acutely and chronically ill participants to support improved health outcomes and costs. Working with a registered nurse, participants, their legal representatives and support networks, physicians, and providers, the Social Worker assesses medical, psychosocial, functional, cognitive, environmental, and social needs; develops and implements plans of treatment; coordinates services and community resources; identifies backup caregivers; and provides education, counseling, advocacy, and referrals. The position monitors service delivery and quality, conducts regular and annual participant visits and reassessments, updates care plans, and follows up after emergency department or inpatient admissions. It maintains timely and accurate case records, consults with staff about social, emotional, and cultural factors affecting care, and builds relationships with community organizations. The Social Worker also participates as a clinical consultant within the Homes Health Program, supporting care coordinators and facilitating access to primary care and behavioral health providers as needed. The role requires independent work and effective interdisciplinary collaboration, strong organization and communication, sound clinical judgment, and the ability to manage a substantial workload within deadlines. It involves travel to sites in San Diego County and possibly Imperial County, with occasional work outside normal business hours. Physical requirements include reaching, bending, stooping, crouching, kneeling, grasping, full range of motion, lifting up to 50 pounds, and frequent indoor and outdoor standing and walking.

Requirements

Bachelor’s degree from an accredited school in Social Work, Gerontology, Psychology, or Marriage Family Therapy.
Valid California driver’s license, access to an insured vehicle, and ability to drive within San Diego County and possibly Imperial County.
At least two years of experience in one or more of the following: managed-care health plan work; utilization review, case management, or discharge planning; or transitional care and acute-care settings such as critical care, acute hospital care, long-term acute care, skilled nursing care, or long-term care.
Ability to thrive in a team environment, maintain good organizational skills, and handle difficult and unusual interpersonal situations effectively.
Knowledge of Microsoft Word, Excel, and PowerPoint.
Computer data-entry, analysis, and reporting experience.
Cultural sensitivity and ability to respect diversity and work effectively with people of different cultures and socioeconomic statuses.
Ability to prioritize and complete a large volume of work within strict deadlines and provide prompt, efficient, responsive customer service.
Basic physical, psychosocial, and functional assessment skills.
Knowledge of HMO and waiver program regulations, eligibility requirements, and plan specifics.
Ability to collaborate across organizational and community resources.
Thorough knowledge of appropriate utilization of acute hospital, long-term care, and home-care resources.
Ability to produce concise yet thorough clinical documentation of patient assessments and care needs.
Strong communication, customer-service, problem-solving, critical-thinking, time-management, organizational, and clinical-judgment skills.
Ability to use computers and electronic health records.
Physical clearance for reaching, bending, stooping, crouching, kneeling, and grasping; full range of motion; ability to lift up to 50 pounds; and ability to stand and walk frequently indoors and outdoors.
TB clearance.
Ability to travel to other sites or locations in San Diego County.
Completion of pre-employment requirements, including I-9, physical, positive background and reference check results, completed application, new-hire orientation, and pre-employment PPDs.

Nice To Haves

Knowledge of Electronic Health Data Systems, including Epic.

Responsibilities

Proactively manage social-service needs of acutely and chronically ill participants to support their plans of treatment, health outcomes, and costs.
Conduct comprehensive health and psychosocial assessments, working with a registered nurse to identify medical, functional, cognitive, environmental, and social needs and appropriate services.
Collaborate with participants, legal representatives, support networks, physicians, and providers to develop plans of treatment with goals reflecting assessed needs, circumstances, and preferences.
Mitigate risk, minimize service disruptions, and identify services available through family, friends, or other publicly funded programs.
Implement plans of treatment by identifying providers and community resources and coordinating timely, effective, and efficient services.
Identify backup caregivers and arrange training when needed so unpaid support is available if scheduled waiver providers do not arrive.
Provide information, education, counseling, advocacy, and referrals to participants and their families.
Monitor HCBA Waiver service delivery and quality, including monthly face-to-face visits or telephone calls to assess health, mood, social integration, functionality, and overall well-being.
Conduct annual face-to-face visits, reassessments, and care-plan updates, and follow up after emergency department and inpatient admissions.
Develop community resources and refer participants and families to appropriate agencies or facilities; serve as liaison and advocate.
Maintain accurate HCBA Waiver case-management records and meet timely documentation standards.
Consult with and advise staff about social, emotional, and cultural factors related to health and medical care and the availability of community social services.
Maintain working knowledge of facility service areas, transportation, community characteristics, and geography.
Network with organizations and, when requested, represent the agency with human-service, health-care, and community groups and individuals.
Attend meetings, teleconferences, and trainings, or arrange for a knowledgeable proxy to attend in place of the program lead.
Serve as a clinical consultant within the Homes Health Program by reviewing and informing participant health action plans, supporting care coordinators as a clinical resource, and facilitating access to primary care and behavioral health providers as needed.
Work independently and effectively as part of an interdisciplinary team; manage projects, activities, timelines, and issues.
Collaborate with physicians, nurses, patients, internal departments, outside agencies, and the public, providing customer-focused service.
Comply with department, organization, and government policies and procedures; attend required meetings and training; model SYH core values and follow attendance and punctuality policies.
Perform other duties as assigned.