• Conducts comprehensive assessments and on-going re-assessments of the client including psychosocial, physical and mental health, environmental and spiritual needs.

• Writes comprehensive assessments. Based on assessment information with the client develops and initiates the Community Living Plan, which is client-centered, comprehensive and consistent with program guidelines and policies and procedures.

• Conducts home visits, acute hospital & skilled nursing facility visits, as well as escorts clients to medical and other appointments as clinically indicated.

• Identifies, arranges for, and monitors appropriate community services based on a good knowledge of Medicare, Medi-Cal, and other entitlement programs.

• Establishes and maintains a care management relationship with clients and their informal support network as appropriate, offering respect, dignity and support. Provides crisis intervention, advocacy, problem solving and therapeutic interventions.

• Meets with clients at least monthly, and more often as clinically indicated. Reviews and modifies their Community Living Plan on an ongoing basis.

• Documents via progress notes all case management activity regarding identified problems within 24-48 hours, adding any new problems to the Community Living Plan, as needed.

• Maintains required paperwork and follows a clear, concise, and consistent system of charting to allow for continuity of care.

• Ongoing evaluation for client Purchase of Service needs and follow-up to determine if services have been provided in a timely manner.

• Educates clients and informal support network about resources.

• Establishes and maintains open and effective communication with community providers, including physicians and other health care and social service workers. Provides appropriate information on all significant aspects of individual client care and program operations, while maintaining necessary confidentiality.

• Monitors the quantity and quality of the services provided by other involved providers.

• Working closely with the team, continuously evaluates the clients’ ability to remain safely at home, coordinates placement as appropriate, according to program guidelines.

• In collaboration with the client, caregiver, and involved services, terminates clients when appropriate. Documents the process as required.

• Participates in research studies and data collection, as required.

• Participates in and promotes ongoing efforts towards Continuous Quality Improvement.

• Attends and actively participates in team and program meetings, activities and problem-solving endeavors; contributes to open lines of communication within the team.

• Utilizes supervision appropriately, maintaining open lines of communication and providing updates on caseload activity.

• Actively incorporates the ethical and legal standards of the National Association of Social Workers into all aspects of interactions with others.

• Understands and applies the regulatory and procedural requirements of the Institute on Aging.

• Attends continuing education classes and/or in-service training to increase knowledge, skills and attitudes related to case management, gerontology, family and community systems and other areas relevant to the Community Living Fund client population.

• All other reasonably related responsibilities as assigned.

EDUCATION:

• M.S.W. (Masters in Social Work) or another appropriate Masters level degree such as an MPH, MFT with additional or specialized work experience such as psychology, counseling, or geriatrics.

• Alternatively, in lieu of a Masters degree, an employee may qualify for a Care Manager II position with a BA or BS in Social Work or another appropriate major and a minimum of two (2) years of relevant social work experience and the ability to demonstrate autonomous work in conceptualizing and formulating biopsychosocial assessments, identifying care needs and necessary interventions, and then executing effective care interventions.

BACKGROUND AND EXPERIENCE:

• One year working with disabled adults and/or older adults required.

• Experience with and understanding of the medical and psychosocial problems of functionally impaired adults and older adults.

• Experience working with individuals with mental and/or behavioral health diagnoses and substance abuse disorders highly desired.

• Exceptional communication and presentation skills relating to functionally impaired adults and older adults, their support systems and teams of health professionals.

• Demonstrates case management skills and experience in the community health care delivery system.

• Detail oriented with good problem solving skills and the ability to prioritize multiple tasks.

• Computer literacy required.

• EPIC electronic medical records experience highly preferred.