Care Manager I

ioaging; Merced (CA); On-site; USD 55,000 - 75,000; Full time

Job summary

Institute on Aging seeks a dedicated social worker to conduct comprehensive client assessments, develop person-centered care plans, and coordinate services to support aging adults at home. You will perform home visits, advocate for clients, and maintain timely documentation while collaborating with a multidisciplinary team.

The role emphasizes ethics, confidentiality, and continuous quality improvement within the Community Living Fund framework.

Qualifications

• B.A or B.S in Social Work or related field required.
• One year working with disabled adults and/or older adults required.
• Experience with mental/behavioral health and substance abuse disorders is highly desired.
• Exceptional communication and presentation skills relating to functionally impaired adults and older adults.
• Demonstrates case management skills in the community health care delivery system.

Responsibilities

• Conducts comprehensive assessments and ongoing re-assessments of the client including psychosocial, physical and mental health, environmental and spiritual needs.
• Writes comprehensive assessments; develops and initiates the Client-centered Community Living Plan.
• Conducts home visits and escorts clients to medical appointments as clinically indicated.
• Identifies and coordinates community services based on knowledge of Medicare, Medi-Cal, and other entitlement programs.
• Maintains a care management relationship with clients and significant others; provides crisis intervention and advocacy.
• Updates progress notes within 24-48 hours and maintains charting for continuity of care.
• Promotes continuous quality improvement and participates in team meetings and problem solving.
• Adheres to NASW ethics and Institute on Aging policies.

Skills

Communication

Case management

Team collaboration

Documentation

Ethics & confidentiality

Gerontology

Education

Bachelor's in Social Work

Job description

IOA is on the forefront of revolutionary healthcare models, reshaping the way people can age in place. Our innovative models transform lives, enhance communities, and save healthcare systems millions of dollars. Rather than focusing on archaic outdated design, we strive to consistently question the "status-quo" and create new and more innovative ways to help aging adults and adults with disabilities maintain their quality of life.

With over 23 programs, we offer multiple ways to aid seniors maintain their health, well-being, independence and participation in the community, fulfilling our mission.

Responsibilities

• Conducts comprehensive assessments and on-going re-assessments of the client and 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 a good knowledge of Medicare, Medi-Cal, and other entitlement programs.
• Establishes and maintains a care management relationship with clients and their significant others 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 care 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 care 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 significant others 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 Community Living Fund guidelines.
• In collaboration with the client, caregiver, and involved services, terminates clients when appropriate. Documents the process as required.
• Participates in 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 Community Living Fund as well as the policies and procedures 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

• B.A or B.S in Social Worker or related field required .

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 the 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