Medical Social Worker II – Care Coordinator

Kaiser Permanente; Santa Clara (CA); Hybrid; USD 80,000 - 110,000; Full time

Job summary

Kaiser Permanente is seeking a Medical Social Worker II to support patients and families in hospital and clinic settings. You will assess psychosocial needs and coordinate care planning, linking patients to Kaiser resources and community services.

The role emphasizes crisis intervention, planning, documentation, and collaboration with a multidisciplinary team to ensure comprehensive social work services aligned with policy and regulations.

Qualifications

• Masters in Social Work accredited by the CSWE.

Responsibilities

• Provide psychodynamic interventions, crisis intervention, grief/bereavement counseling, problem solving and coping strategies.
• Develop and implement an individualized Plan of Treatment addressing social, emotional, financial and environmental factors.
• Complete psychosocial assessments and collaborate with patient to develop mutually agreed treatment plans.
• Discuss care options including Kaiser resources and external resources for short and long-term planning.
• Collaborate with multidisciplinary teams to address biopsychosocial needs of patients and families.
• Assist patients in advocating for services within Kaiser and in the community.
• Coordinate care planning and discharge planning, ensuring timely and accurate documentation.
• Facilitate appropriate placements and liaise with nursing facilities and Kaiser personnel.

Skills

Teamwork

Psychosocial assessment

Communication

Documentation

Computer literacy

Education

MSW

Tools

EHR

Job description

Job Summary:

The primary role of the Medical Social Worker II is to assist patients and families/caregivers to cope with the social/emotional issues and practical arrangements related to the patients illness. Under general direction of the Social Work Manager/LCSW, delivers age-appropriate social work care to patients and their caregivers in accordance with agency policy and procedure and state and federal regulations. The Medical Social Worker II serves as an integral member of the healthcare team providing assessments, coordination, treatment planning, information and referral to community resources and other social work services to meet the complex needs of patients and families in the hospital and clinic settings.

Essential Responsibilities:

• Provides psychodynamic interventions, crisis intervention, grief/bereavement counseling, problem solving, stress reduction and developing healthy coping strategies in individual/family/group settings. Provide counseling for disease acceptance and understanding.
• Responsible for developing and implementing individual Plan of Treatment which assist patients and families to cope and/or restore social, emotional, financial and environmental factors which affect and/or affected by illness.
• Completes psychosocial assessments. Partners with patient to identify needs and develop and implement individual treatment plan based on mutually agreed upon treatment plan.
• Discuss options for care proactively including Kaiser resources and external community/government resources to assist patient and family in developing short and long term care plans as appropriate.
• Team with other disciplines in assessing, planning and providing services for patients utilizing biopsychosocial information.
• Assist patient in advocating for self to receive appropriate services within Kaiser and in the community.
• Assist patient and family with care planning and discharge plans.
• Takes, reviews, evaluates and prioritizes written and oral referrals.
• Maintains documentation, records and data collections.
• Responsible for completion of required documents in a complete and timely manner.
• Functions as part of the Skilled Nursing Facility Team to assure appro priate, timely placement of Kaiser members in nursing facilities.
• Liaison between patient and Kaiser maintaining positive relationship with Kaiser and providing for continuity of care.
• Identifies appropriate levels of care and facilities for referred patients, were applicable.
• Obtains placements, where applicable.
• Collaborate with internal and external resources in Kaiser and the community to meet mutually agreed upon goals and objectives.
• Provides information and referral to community resources as requested.
• Coordinates exchange of information between Kaiser, families, members and skilled nursing facilities.
• Determines application of Kaiser, Medicare and Medi-Cal benefits to specific patient situations.
• Participates in Utilization Management/Quality Assurance activities.
• Assist in coordinating communication between regional offices, clinics, hospitals, and field staff, triaging of phone calls from members/families.
• Works with referral sources to clarify and complete required clinical and psychosocial information.
• Perform other related duties as necessary.

Basic Qualifications:

Experience

• Step I: 0 - 2 years social work experience.
• Step II: 2 - 4 years social work experience within the last five (5) years.
• Step III: 4 or more years social work experience within the last ten (10) years.

Education

• Masters in Social Work accredited by the Council of Social Work Education.

License, Certification, Registration

• N/A

Additional Requirements:

• Demonstrated ability to work on a multidisciplinary team.
• Must have solid psychosocial assessment skills.
• Knowledge of chronic and acute disease and how it impacts patient and family functioning.
• Demonstrated excellent oral/telephone communication skills and written documentation.
• Must be computer-literate and, preferably, experienced in automated clinical information systems.
• Must demonstrate ability to effectively and efficiently handle demanding workload involving multiple tasks.
• Demonstrated ability to function independently as a collaborative, supportive team member.
• Must be able to master detailed and complex information regarding benefits and coordination of care.
• Must be willing to work in a Labor Management Partnership environment.
• Also refer to Position Specifications outlined in the appropriate collective bargaining agreement.

Preferred Qualifications:

• LCSW preferred.

• At least one (1) year post MSW experience in a health care setting preferred- MSW internship may be considered in lieu of this requirement.