Social Work Case Manager

Open Door Community Health Centers; United States; On-site; USD 40,983 - 47,430; Full time

Job summary

Open Door Community Health Centers is looking for a dedicated Social Work Case Manager to join their team. This role focuses on assisting patients by navigating social determinants of health, ensuring they have access to vital resources and support. The ideal candidate will have a Bachelor’s degree in a relevant field and experience in case management.

Responsibilities include collaborating with care teams, managing complex cases, and participating in quality improvement activities. Open Door is committed to serving marginalized communities while fostering a supportive work environment.

Qualifications

• Strong interpersonal skills to establish working relationships.
• Effective listening and motivational interviewing skills.
• Knowledgeable of trauma's effects on populations experiencing poverty.

Responsibilities

• Assist patients navigating social determinants of health.
• Maintain effective relationships with community resources.
• Develop individualized case management treatment plans.

Skills

Interpersonal skills

Active listening

Cultural humility

Time management

Problem-solving

Knowledge of trauma

Education

Bachelor’s degree in social service or health-related field

Two years of experience in similar role

Tools

Microsoft Office Suite

Electronic Medical Records (EMR)

Job description

Committed to Our Community in the Heart of the Redwoods. Removing Barriers to Healthcare Access FoCHC Fortuna Community Health Center A Social Work Case Manager (SWCM) at Open Door Community Health Centers (ODCHC) provides integrated, supportive and enabling services to health center patients. The SWCM collaborates with an interdisciplinary care team to ensure continuity of care and assist patients in accessing services and utilizing resources to support their medical, psychological, and socioeconomic needs. The SWCM identifies and addresses a variety of non-clinical social determinants of health (SDoH) to promote positive health outcomes and reduce health inequities. The SWCM is dedicated to serving marginalized or otherwise underserved populations with lowest access to resources in our community.

Compensation Range: $29.75-$34.43. Hmong and Spanish speakers who successfully pass a language exam will receive a minimum additional $0.75 hourly differential to their wage.

Essential Duties and Responsibilities

• Assist patients in navigating the social determinants of health (SDoH) to provide effective interventions, improve health outcomes, and increase accessibility to resources.
• Maintain knowledge of and effective relationships with community resources, benefit programs and social service providers.
• Provide direct assistance with eligibility, referral, documentation, navigation, education, enrollment and follow‑up when necessary.
• Assess the biopsychosocial needs of each patient.
• Identify individual barriers, strengths, and areas of need to formulate an individualized effective case management treatment plan and implementation strategies.
• Collaborate with patients and care teams to develop a plan to overcome obstacles and find solutions.
• Meet regularly with patients.
• Utilize proactive and flexible delivery of evidence‑based approaches.
• Employ strategies to engage patients and families in achieving goals and optimizing health.
• Manage complex cases and ensure services across the continuum of care.
• Identify and facilitate appropriate referrals to alcohol and drug programs, disability services, employment & training programs, mental health providers, housing services, family resources, transportation, long‑term care planning, social services, resources for food and financial security, county, state, and federal programs, and other community sources of support based on patient need.
• Be knowledgeable in de‑escalation techniques, crisis intervention, trauma response, and safety planning.
• Practice a harm reduction, strengths‑based, and informed consent approach.
• Participate in facilitation of peer support and educational groups within internal case management, behavioral health, and substance use programs as directed.
• Liaise with internal and external programs or agencies to promote interagency collaboration.
• Participate in case conferences with primary care teams, behavioral health clinicians, discipline‑specific supervisors and other case managers for feedback, education, and support.
• Enable consultation with interdisciplinary providers such as psychiatry, medication‑assisted treatment, intensive outpatient nurse case management and other embedded programs as needed.
• Meet standards for referrals, tracking, and reporting set by department.
• Participate in quality improvement and risk management activities.
• Actively participate in program development, planning, implementation, and evaluation.
• Monitor systemic barriers and access to care issues.
• Communicate recommendations to supervisor and clinic leadership on areas for future attention.
• Contribute positively to the efficiency, accessibility, productivity, quality, safety, compassion, and professionalism of the work setting.
• Perform other duties and responsibilities as identified and assigned by supervisor.

Qualifications and Expectations

• Strong interpersonal skills and the ability to establish constructive professional working relationships among a diverse workforce.
• Effective active listening, motivational interviewing, emotional intelligence, cultural humility, and critical thinking skills to engage a diverse population of patients and families.
• Ability to advocate for patients, encourage independence, and assist in development of skills to manage challenges and make healthy decisions to support mutual goals.
• Solutions oriented with a creative problem‑solving approach.
• Knowledgeable of the effects of trauma and how it can impact families experiencing poverty, food insecurity, substance use problems, housing insecurity, and other SDoH.
• Familiar with evidence‑based practices and patient‑centered care such as trauma‑informed, resilience‑oriented framework.
• Works well under pressure with minimal supervision.
• Excellent time management and organizational skills.
• Flexible and able to handle multiple cases and competing demands simultaneously.
• Functions well within an interdisciplinary team.
• Acts as a contributing member of the care team offering a collaborative approach to treatment.
• Keeps team informed about progress towards goals and any changes to the care plan.
• Ability to handle difficult or confrontational situations in a calm, consistent, and equitable manner.
• Detail oriented and patient.
• Ability to accurately write comprehensive chart notes as well as routine correspondence.
• Able to complete extensive forms and paper applications.
• Ability to effectively represent ODCHC’s interests in the community and maintain effective working relationships among co‑workers, public, private, and professional groups.
• Strong computer skills with specific aptitude in Microsoft Office Suite and/or Electronic Medical Records (EMR).
• Adheres to National Association of Social Work Code of Ethics: Service, Integrity, Social Justice, Competence, Importance of Human Relationships, Dignity and Worth of the Person.
• Adheres to ODCHC’s policies and procedures.

Education and Experience

• Bachelor’s degree in social service or health‑related field or an equivalent combination of education and experience required; Master’s or related advanced degree preferred.
• Two years of experience in a similar role; or an equivalent combination of education and experience.
• Demonstrated experience working with intersectional marginalized populations, including persons diagnosed with mental illness, a disability, seniors, houseless, and/or substance‑dependent patients.
• Knowledge of local community resources and agencies providing social services.
• Experience with eligibility for public benefits such as Medi‑Cal, Medicare, Social Security, CalFresh, Unemployment, and State Disability benefits is preferred.
• Bi‑lingual competency in Spanish or Hmong preferred.

Supervisory Responsibilities

• None.

Physical Requirements

• Office‑based position with reasonable accommodation for qualified candidates.
• Ability to communicate via telephone, video, and/or in‑person.
• Vision adequate to read documents, computer screens, and forms.
• Ability to remain stationary for extended periods.
• Ability to lift, carry, or otherwise move up to 25 pounds.
• Ability to use keyboard and view computer screens for extended periods.
• Ability to travel locally and long‑distance as needed.
• Ability to move around offices and clinics as needed.

Additional Information

Open Door participates in the E‑Verify program. Open Door participation in E‑Verify is voluntary for our organization, but we are committed to maintaining a legal and compliant workforce.

Notice of Non‑Discrimination: Open Door Community Health Centers does not discriminate based on citizenship status or national origin in accordance with 8 U.S.C. § 1324b.