Job Summary: The Social Work Care Manager is a member of the multidisciplinary care coordination team. The Social Work Care Manager works in partnership with nurse care manager(s), care coordinators, peer health coach medical provider(s), and external partners such as hospitals and the County Department of Health Services to assess the behavioral needs of clients experiencing homelessness, focusing on mental health and substance abuse screening and referral; education and counseling; and education and training on skills building with clients to help them learn to self-manage chronic disease.
Specific Tasks/Duties Include:
Adhere to the medical case management standards. Primary duties are described below:
Face-to-face psychosocial assessment for all clients to include an appraisal of the general overall appearance, demeanor, and effect of the client as part of the intake and on a schedule determined by the acuity scale.
In collaboration with the nurse care managers, care coordinators, peer health coach, and medical providers will assist in the development, periodic re-evaluation, and revision of a comprehensive individualized care plan for all clients.
Provides outreach into the community including hospitals, homeless service programs, County DHS programs, and street outreach to connect homeless individuals and homeless families with holistic health, mental health, substance use, and social service programs and activities.
Education and counseling on referrals to behavioral health services.
Education and counseling, as appropriate, to assist clients to develop positive behavior change related to mental health, substance use, and self-management.
Referral, follow-up, and advocacy to appropriate agencies required to assist the client in achieving the goals and objectives identified in the individualized care plan.
Case conferencing with the client’s mental health provider, substance abuse treatment provider, and any other professional working with the client on enhancing their behavioral choices.
Case conferencing with the care team as appropriate and as required by acuity level.
Document according to grant tracking and reporting requirements.
Advocacy on behalf of clients with mental health and substance abuse treatment programs and other agencies, developing and maintaining strong working and referral relationships.
Documentation in progress notes on the required forms and in the electronic health record.
Facilitate support groups.
Participate in ongoing training.
Other duties as assigned.
Master’s Degree in Social Work required LCSW preferred
Minimum 1-year experience providing case management services.
Knowledge and Skills:
Fluency in English and Spanish (speak, read and write) preferred.
Experience working with people experiencing homelessness preferred.
Knowledge of community resources for people experiencing homelessness.
Cultural competency with the patient populations.
Demonstrates knowledge of compliance issues within the community clinic environment.
Maintains confidentiality of patients at all times by complying with HIPAA policies.
Strong interpersonal skills; ability to be sensitive with persons of various social, cultural, economic, and educational backgrounds.
Proficiency with Microsoft Office applications including Outlook, Word, Excel, and PowerPoint.
Strong organizational skills with the ability to prioritize projects, work relatively independently, manage multiple tasks, and meet deadlines.
Strong written and verbal communication skills.
Ability to work independently and as part of a team.
Good judgment, problem-solving, and decision-making skills.
While performing the duties of this job, this position is frequently required to do the following:
Use standard office equipment and access, input, and retrieve information from a computer. Use computer keyboard with manual and finger dexterity and wrist-finger speed sufficient to perform repetitive actions efficiently for extended periods of time.
Communicate effectively in person or via telephone in a manner that can be understood by those with whom the person is speaking, including a diverse population.
Give and follow verbal and written instructions with attention to detail and accuracy.
Perform complex mental functions and basic arithmetic functions; interpret complex laws, regulations, and policies; collect, interpret, and/or analyze complex data and information.
Vision: see details of objects at close range.
Coordinate multiple tasks simultaneously.
Reach forward, up, down, and to the side.
Sit or stand for minimum periods of one hour at a time and come and go from the work area repeatedly throughout the day.
Lift up to ten (10) pounds.
Internal Number: 6420
About Santa Rosa Community Health
Santa Rosa Community Health serves our diverse community by providing excellent, culturally responsive, comprehensive primary care that is accessible to all people. We care for the whole person with compassion and respect. We cultivate a safe, supportive learning environment where employees can do their best work in a way that embraces diversity. We advocate for health care as a human right because it is fundamental to social justice.
Our vision is to improve the health and well-being of our community by transforming the health care experience so that all people have access to care and all people feel cared for; to create a lasting health care resource for our community; and to be an integral partner with the community in the promotion of health, education, and access to care. We believe that equal access to health care is essential to social justice.