SLH Care Management Social Worker II

About the Role

Restores patients to optimum health and social adjustment while facilitating a positive impact on the hospital transition of care. Informs the healthcare team of the patient's social, emotional, environmental, and financial needs and resources that may influence their treatment options and discharge plan. Assists case manager nurses with complex social cases and discharge planning, provides therapeutic counseling, and is responsible for clinical supervision.

Responsibilities

• Provides direct clinical supervision of miscellaneous non-licensed clinicians (including students) and mentorship to all levels of social work in current social trends and practice.
• Performs psychosocial assessment interviews with patients and/or families and records this assessment in the patient's medical record; assesses patient's level of functioning, environment, and support system related to illness and ability to cope.
• Reassesses the patient's condition when changes occur and revises the care plan as appropriate; performs rapid assessments and develops crisis management plans for referral, evaluation, and admission.
• Provides therapy services as necessary and supports special integration of mental health and medical services projects.
• Coordinates patient care activities with other members of the healthcare team, the patient, the patient's representatives, and community partners; makes referrals as appropriate.
• Maintains patient records including assessments, plans, interventions, patient/family involvement, outside agency communications, and interdisciplinary contacts.
• Screens for barriers to care such as substance abuse, neglect, financial limitations, or housing; intervenes regarding emotional, behavioral, and financial barriers to current illness and/or disability.
• Provides patient advocacy, including initiating processes regarding capacity determinations, grief counseling, conservatorship/guardianship, and adoption/surrogacy cases.
• Serves as a resource and provides counseling related to palliative care or end-of-life planning.
• Intervenes in suspected abuse/neglect cases and in complex or high-risk situations; identifies and responds to high-risk behaviors and traumas.
• Participates in discharge planning activities; identifies and intervenes with high-risk discharge planning issues with psychosocial complexity.
• Assists Care Management Nurses with discharge planning efforts; obtains or coordinates referrals for post-discharge service needs.
• Mobilizes resources to achieve targeted discharge times; identifies potential problems and resolves variances to the care management plan.
• Coordinates family and community resources to meet identified needs and supports the discharge plan.
• Identifies and mobilizes patient and family strengths to optimize healthcare and community resource use; guides in securing post-discharge services.
• Refers and assists patients/families in applying for financial programs (CCS, SDI, SSI, SSD, private pensions) and legal instruments as needed.
• Collaborates with the Care Transition team and Health Advocates for high-risk patients to ensure timely follow-up appointments and linkage to community services.
• Serves as a content expert for educational training and leads patient-centered conferences.
• Participates in continuous quality improvement of social work-related activities in the department.

Requirements

• Master's degree in social work/welfare issued by a school accredited by the Council of Social Work Education.
• Three years of social work or case management experience in an acute setting or protective services.
• Valid license as a Clinical Social Worker issued by the State of California Board of Behavioral Science Examiners.

Preferred Qualifications

• Two years of experience in managing and providing clinical supervision.
• Active certification in Case Management (ACM or CCMC).

Pay

Pay range: $46.35 - $77.25 per hour. Final compensation will be determined based on experience, education, skills, licensure, certifications, departmental equity, applicable collective bargaining agreements, and operational needs.

Benefits

Alameda Health System offers eligible positions a generous comprehensive benefits program.