What you will be doing
Clinical Practice & Case Management
- Exercise independent judgment to provide case management services for a panel of patients.
- Conduct comprehensive initial and routine psychosocial assessments to develop, implement, and update individualized care plans.
- Collaborate with caregivers and support systems to establish and deliver coordinated care plans.
- Identify psychosocial risks, challenges, and service needs; advocate, refer, coordinate, and follow up on patient support in a timely manner.
- Provide individual counseling to patients as needed.
- Facilitate family conferences and patient/caregiver support groups.
- Engage with the community to identify and access services that support patient well-being.
- Conduct discharge planning and coordination when a patient transitions out of the program.
- Participate in special events such as caregiver workshops and educational sessions.
- May review and verify assessments completed by other social work staff.
- Serve as a primary liaison between patients, caregivers, the team, and community partners.
- Collaborate with external agencies such as healthcare plans, community-based organizations, and care facilities.
- Adhere to ethical and legal standards of social work practice.
- Comply with all organizational policies and procedures, including safety and confidentiality regulations.
- Complete all documentation promptly and accurately.
- Actively participate in team meetings, advocate for patient and caregiver needs, and contribute to collaborative care planning.
- Support continuous improvement efforts to enhance service quality and operational efficiency.
- Deliver 5-star service guided by compassion, respect, and professionalism.
- Perform other related duties as assigned.
What you must have
- Master’s degree in Social Work (MSW) from an accredited institution required.
- Bachelor’s degree in Social Work may be considered with relevant experience and language proficiency.
- Minimum of one (1) year of experience working with frail or elderly populations.
- Valid Social Worker license in the state of California (MSW – Medical Social Worker).
- Experience and ability to work effectively with diverse populations.
- Skilled in collaborative teamwork and interdisciplinary care coordination.
- Strong interpersonal skills with the ability to build trust and rapport with patients, caregivers, and colleagues.
- Highly organized with the ability to prioritize, manage multiple tasks, and follow up thoroughly.
- Excellent verbal and written communication skills.
- Proficient in Microsoft Office and comfortable using electronic documentation systems.
- Bilingual ability may be required for specific assignments.
- Strong foundation in clinical practices and case management principles.
Nice to have
- One (1) year or more of post-MSW experience.
- Prior experience in case management or healthcare settings.
- Familiarity with electronic health record (EHR) systems.