Social Work Case Manager

Open Door Community Health Centers•Arcata, CA

1d•Onsite

About The Position

A Social Work Case Manager (SWCM) at Open Door Community Health Centers (ODCHC) provides integrated, supportive, and enabling services to health center patients. Working with an interdisciplinary care team, the SWCM supports continuity of care and helps patients access services and resources for their medical, psychological, and socioeconomic needs. The role identifies and addresses non-clinical social determinants of health to promote positive health outcomes and reduce health inequities, with a focus on marginalized and underserved community members who have limited access to resources. The position assesses patients’ biopsychosocial needs, develops individualized case-management plans, and helps patients navigate community resources and public benefits. The SWCM coordinates referrals and follow-up, supports patients and families in reaching their goals, manages complex cases across the continuum of care, and collaborates with internal and external programs. The work also includes participating in case conferences, peer-support and educational groups, quality improvement and risk management activities, and program development and evaluation. Compensation is $29.75–$34.43 per hour. Hmong and Spanish speakers who pass a language exam receive a minimum additional $0.75 hourly differential. The role is largely office-based and may require local and long-distance travel as needed.

Requirements

Bachelor’s degree in a social-service or health-related field, or an equivalent combination of education and experience.
Two years of experience in a similar role, or an equivalent combination of education and experience.
Demonstrated experience working with intersectional marginalized populations, including people diagnosed with mental illness, people with disabilities, seniors, people experiencing homelessness, and/or people with substance dependence.
Knowledge of local community resources and agencies that provide social services.
Strong interpersonal skills and the ability to build constructive professional relationships across a diverse workforce.
Active listening, motivational interviewing, emotional intelligence, cultural humility, and critical-thinking skills for engaging diverse patients and families.
Ability to advocate for patients, encourage independence, and support development of skills for managing challenges and making healthy decisions.
Solutions-oriented approach and creative problem-solving skills.
Knowledge of trauma’s effects on families experiencing poverty, food insecurity, substance-use problems, housing insecurity, and other social determinants of health.
Familiarity with evidence-based practices and patient-centered care, including trauma-informed and resilience-oriented frameworks.
Ability to work under pressure with minimal supervision and manage time and competing demands effectively.
Ability to function as a collaborative member of an interdisciplinary care team.
Ability to handle difficult or confrontational situations calmly, consistently, and equitably.
Attention to detail and patience; ability to write comprehensive chart notes and routine correspondence accurately and complete extensive forms and paper applications.
Ability to represent ODCHC effectively in the community and maintain working relationships with coworkers and public, private, and professional groups.
Strong computer skills, particularly with Microsoft Office Suite and/or electronic medical records (EMR).
Adherence to the National Association of Social Workers Code of Ethics and ODCHC policies and procedures.
Ability to communicate by telephone, video, and/or in person; read documents, computer screens, and forms; remain stationary for extended periods; use a keyboard and view computer screens for extended periods; lift, carry, or otherwise move up to 25 pounds; travel locally and long-distance as needed; and move around offices and clinics as needed.

Nice To Haves

Master’s or related advanced degree.
Experience with eligibility for public benefits such as Medi-Cal, Medicare, Social Security, CalFresh, Unemployment, and State Disability benefits.
Spanish or Hmong bilingual competency.

Responsibilities

Help patients navigate social determinants of health through effective interventions and access to resources.
Maintain knowledge of and effective relationships with community resources, benefit programs, and social service providers.
Assist patients with eligibility, referrals, documentation, navigation, education, enrollment, and follow-up.
Assess each patient’s biopsychosocial needs, barriers, strengths, and areas of need.
Develop and implement individualized case-management plans with patients and care teams.
Meet regularly with patients and use proactive, flexible, evidence-based approaches to engage patients and families in achieving goals and optimizing health.
Manage complex cases and coordinate services across the continuum of care.
Identify and facilitate referrals to alcohol and drug programs, disability services, employment and training programs, mental health providers, housing services, family resources, transportation, long-term care planning, social services, food and financial security resources, public programs, and other community supports.
Use de-escalation, crisis intervention, trauma response, and safety-planning practices, and apply harm-reduction, strengths-based, and informed-consent approaches.
Participate in and assist with peer-support and educational groups within internal case-management, behavioral-health, and substance-use programs as directed.
Liaise with internal and external programs and agencies to promote interagency collaboration.
Participate in case conferences with primary-care teams, behavioral-health clinicians, supervisors, and other case managers.
Facilitate consultation with interdisciplinary providers and embedded programs as needed.
Meet department standards for referrals, tracking, and reporting.
Participate in quality-improvement and risk-management activities.
Contribute to program development, planning, implementation, and evaluation.
Monitor systemic barriers and access-to-care issues and communicate recommendations to the supervisor and clinic leadership.
Contribute to an efficient, accessible, productive, high-quality, safe, compassionate, and professional work setting.
Perform other duties and responsibilities assigned by the supervisor.
Keep the care team informed about progress toward goals and changes to the care plan.