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Job Objective: A brief overview of the position.
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The Social Worker is responsible for the delivery of behavioral and healthcare management services in the Ambulatory Care setting to a variety of patient populations across the lifespan; coordinates the complex needs of patients and their families as well as psychosocial assessment for patients with complex psychiatric, social, medical and financial needs.
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Reports to
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Director-Ambulatory Care Coordination
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Supervises
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N/A
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Ages of Patients
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Pediatric
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Adolescent
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Adult
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Geriatric
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Blood Borne Pathogens
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Minimal / No Potential
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Qualifications
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Education
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Required: Master’s degree in Social Work
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Licensure/Certification
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N/A
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Experience
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Required: Two (2) years clinical social work experience; may include internship
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Preferred: Managed care experience, recent medical and mental health experience
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Essential Responsibilities
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Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations.
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Conducts comprehensive biopsychosocial assessments to understand patient’s life story, needs, goals and preferences, including understanding cultural and linguistic factors, in the areas of behavioral health, substance use, abuse/neglect, financial, medical and other needs.
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Facilitates behavioral change necessary for meeting diagnosis and treatment goals, including promoting patient motivation to participate in care and reach treatment goals.
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Facilitates and provides tailored social and emotional support for the patient related to coping with problem(s) being addressed.
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Helps the patient contextualize health education provided by the patient’s treatment team and educates the patient and/or caregiver on how to best participate in medical decision-making.
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Performs periodic administration of SDOH survey tools and monitoring of related SDOH.
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Conducts screenings to evaluate the needs of patients for behavioral health and support services.
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Provides SDOH management services for behavioral health conditions, including psychoeducational counseling and crisis intervention as necessary.
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Sets personalized goals and creates action plans and conducts follow-up/on-going interventions as appropriate.
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Builds patient self-advocacy skills in ways that are more likely to promote personalized and effective treatment of their problem(s) identified.
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Coordinates with clinical, health education, community health and other team members in the provision of services to patients and care transitions.
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Helps the patient arrange access to medical care, including securing medical or community-based appointments, identifying appropriate providers for care needs, identifying appropriate community-based resources for SDOH related to problem(s) identified during the initiating visit, and for accessing all clinical care services necessary.
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Performs coordination of receipt of needed services from practitioners, providers and facilities, home and community based services, and caregiver if applicable.
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Conducts coordination of care transitions between and among health care practitioners and settings, including referrals to other clinicians.
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Conducts communication to and from practitioners, home and community-based services regarding the patient’s psychosocial needs, functional deficits, goals, and preferences.
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Serves as a resource to interdisciplinary team concerning social issues.
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Serves as a field instructor for social work students as well as a mentor to social work team.
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Collaborates with interdisciplinary team to promote continuous process improvement, which results in efficiency, cost effectiveness, and the highest level of clinical excellence.
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Calls in and writes APS, CPS and suspicious injury reports in collaboration with the interdisciplinary team when warranted.
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Documents following documentation standards and demonstrates intervention that supports services provided.
- Performs other duties as assigned.
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Located in the heart of the Coachella Valley, you have access to resort-style living and world-class amenities throughout Southern California.
