Licensed Social Worker

We are seeking a Licensed Social Worker to join our interdisciplinary care team as part of the Care at Home Solutions program. As an independently licensed clinician, you will partner closely with the Medical Director, Advanced Practice Provider (APP), Registered Nurse (RN), Pharmacist, Community Health Worker (CHW), and Care Navigators to address behavioral health needs, improve psychosocial well-being, and support patients in achieving their health goals.

About the role

This is a full-time, hybrid position based in our LA office with up to 50% travel. The role reports to the Director of Care at Home Solutions and operates under standard business hours with flexibility based on patient and program needs.

Responsibilities

• Assess identified patients to determine appropriateness for management early in their disease process and at any time during the continuum of care.
• Complete comprehensive assessments to identify patient risk and develop care plans utilizing expertise and judgment to evaluate needs for alternative services.
• Assess members’ Social Determinants of Health, such as housing, food, transportation, and safety in the home.
• Collaborate with APPs, physicians, and community resources including pharmacists, nurses, registered dieticians, and other disciplines to address patient needs as identified in assessments.
• Assess and screen members for behavioral health concerns (depression/substance abuse) utilizing screening tools, including the PHQ2 and 9 Depression screenings, and ensure they receive appropriate behavioral health interventions.
• Facilitate necessary follow-up or referrals for behavioral health needs with local behavioral health providers.
• Develop, facilitate, and communicate a plan of care in partnership with the member, family (or designated representatives), providers, and multidisciplinary care team to assess care options, including use of benefits and community resources.
• Update care plans to include progress toward achieving established goals and self-management activities.
• Coordinate necessary referrals and authorizations pertinent to patient care and well-being.
• Utilize developed systems, processes, and initiatives to engage patients in relevant social activities necessary to promote wellness and care at the right place and time.
• Facilitate member adoption of strategies to promote physician-recommended behavior changes.
• Identify and utilize cultural and community resources, aligning with the patient’s cultural preferences as much as possible.
• Facilitate information flow between health representatives and the care team.
• Coordinate care and communicate with multiple providers, both internal and external to the practice.
• Act as a resource for both clinical and non-clinical staff (e.g., care coordinators, community health workers, APPs).
• Attend required training and collaboration sessions (e.g., learning sessions/practice team meetings) as scheduled.
• Provide and facilitate open communication regarding patient status with physicians and the Care at Home Solutions team.
• Perform other job-related duties as assigned.

Requirements

• Valid and current LCSW, LMHT, LPCC, LMFT, LCADAC, LICSW, or LMSW CA licensure.
• 3-5 years’ care management and/or managed care experience in one of the following settings: acute inpatient, rehabilitation, sub-acute, skilled facility, homecare, ambulatory care management, or managed health plan.
• 2-5 years of leadership experience in a care management/managed care setting (preferred).
• Bilingual Spanish/English strongly preferred.
• Working knowledge of timely and accurate documentation of day-to-day activities in designated technology platforms.
• Adaptable to new technologies and software; proficiency in EMR system(s), Outlook, and data entry experience preferred.
• Basic PC skills (MS Word, Outlook, PowerPoint, Excel).
• Knowledge of Federal and State regulations for Medicare and Medicaid and other national and state-funded programs.
• Knowledge of community resource access.

Skills

• Ability to use independent judgment and manage confidential information.
• Strong analytical and problem-solving skills, with attention to detail and data-driven decision-making.
• Excellent communication, listening, and interpersonal skills.
• Ability to clearly communicate medical information to professional practitioners and/or the public.
• Strong organization, prioritization, follow-up, and time management skills with the ability to handle multiple priorities and deadlines.
• Good interpersonal skills, sense of urgency, proactive approach, and ownership of work.
• Dependable with strong work ethics and high personal integrity.
• Ability to manage multiple interruptions in a fast-paced environment while maintaining a friendly demeanor.
• Ability to develop and implement new approaches to improve processes, procedures, or the general work environment.
• Ability to review critical issues, solve problems effectively, and create action plans.

Physical/Mental Demands and Work Environment

• Regularly required to walk, bend, sit, talk, lift, or hear.
• Regularly required to stand, walk, and use hands and arms to operate general office equipment (PC, telephone, file cabinets, copier, postage meter, fax machine, and printer).
• May occasionally lift and/or move between 10 and 25 pounds.
• Specific vision abilities required include close vision and the ability to adjust focus.
• May need to travel to healthcare practices.
• Noise level in the work environment is usually low to moderate.

Pay

Salary range: $75,000 - $96,000.

Benefits

We offer comprehensive, affordable insurance plans for team members and their families, along with unique benefits such as a yearly stipend for wellness-related activities and a paid parental leave program.