Social Worker (Home visits in Fresno)

Alignment Healthcare•Fresno, CA

4d•Hybrid

About The Position

Alignment Health is seeking a social worker to join the Care Anywhere team to conduct home / SNF visits in Fresno (4 home visits per day with mileage reimbursement) and telehealth visits for Madera and Merced. The Social Worker assesses and evaluates members’ needs and requirements to achieve and/or maintain their health. Guides members and their families toward and facilitates interaction with resources appropriate for their care and well-being. Works in collaboration with a multi-disciplinary teams, employing a variety of strategies, approaches and techniques to enable a member to manage their physical, environmental and psycho-social health issues.

Requirements

Minimum 5 years of experience in care management, assessment, long term member/patient care management or community based resource delivery.
2 years experience with vulnerable adults or older adult population.
1 year experience with motivational interviewing-Ability to apply Motivational Interviewing and Appreciative Inquiry.
Master’s Degree in Social Work (MSW)
Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.
Intermediate to advanced computer skills and experience with Microsoft Word and Excel.
Skill to understand current and potential needs of members to take appropriate action in order to support member in health and well-being changes.
Skill in building trust in partnership with member/client/patient.
Basic knowledge of complex care management and care management principles.
Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors.
Ability to perform mathematical calculations and calculate simple statistics correctly.
Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
Comprehend and analyze statistical reports.
Current, valid, unrestricted California Driver's License and reliable transportation.

Nice To Haves

Crisis intervention training
Valid unrestricted Social Worker license (LCSW)

Responsibilities

Conducts telephonic outreach to assigned members to assess health, environment, nutrition, and psycho-social areas of concerns using a variety of assessments.
In response to assessments, coaches and problem solves with member to identify and address specific goal(s) to support health and behavior change.
Provides appropriate interventions to optimize health and well-being. Interventions may include education, the coordination of community-based support services, and other resources.
Charts member's treatments and progress in accordance with state regulations and department procedures.
Makes referrals to case manager, as appropriate, and/or refers member's family to community support services and resources.
Provides home assessment to high-risk members and develop an individual care plan.
Collaborates with physicians in screening and evaluating members for psychotropic medications.
Understands the clinical program design, program monitoring and reporting to better serve members and implement the model of care.
Practices as an interdependent member of the health team and provides important components of primary health care through direct social work services, consultation, collaboration, referral, teaching, and advocacy.
Assesses and treats outpatients in individual and family modalities exercising mature professional judgment and using a wide range of social work skills to include individual and family counseling to assist patients and their families in dealing with chronic and acute diseases/injuries.
Conducts psychosocial assessments to determine patient needs and resources (both family support and community support). Provides counseling to patient and family in matters directly related to patients’ limitation, adjustment to medical condition, and ongoing treatment.
Develops and implements discharge plans, follow-up care, and transfers to other health care facilities (e.g., nursing homes, rehabilitation hospitals, etc.).
Provides consultation services to medical, nursing, and ancillary hospital staff regarding psychosocial issues, discharge plans, and follow-up care for patients and families.
Provides crisis intervention services.
Responds independently, and with various media, to appropriate community requests. Takes the initiative in seeking out opportunities to present programs to meet the needs of patients/members and their families.
Consults with Hospital administration, and Plan supplying information and feedback regarding procedures and services provided by the Psychology Division.
Develops and maintains working relationships with community resources. Coordinate with physicians, and representatives of their service disciplines for the benefit of the member and their families. Takes initiative in identifying and assessing the needs of the community and organize responses to address those needs.
Interfaces with the RN Case Manager(s) and the Interdisciplinary Team (IDT) in the development and implementation of the Case Management Program (CMP).
Integrates social work case management and nurse case management as a team.