As a member of the Care Team, the social worker supports the patient and family regarding benefits, community resources, referrals for counseling and other behavioral health needs. In addition, the social worker must be able to assist the patient in a sensitive and supportive manner, while acting as an advocate on behalf of the patient.
Essential Functions and Responsibilities of the Job
1. Contributes effectively to the overall function and organization of the Medical Management
Department for Memorial Medical Foundation
2. Assess, develop and deploy follow thru for all social work activities and UM/CM delegation requirements
3. Monitor and implement all regulatory changes impacting care
4. Be at work and be on time
6. Follow company policies, procedures and directives
7. Interact in a positive and constructive manner
8. Prioritize and multitask
Essential Job Outcomes
Perform psychosocial assessments
Support MCMF populations including Managed Care and ACO as needed for social work needs.
Perform assessments and develop care plans as needed in the Electronic Medical Record for social work cases.
Collaborate with and support the clinical case management team.
Role requires work time both in a centralized office. within Provider clinics and in the home in specific warranted circumstances and per standard work guidelines
Contribute as needed to process design/redesign.
Provide resources in support of member needs.
As a mandated reporter, submit referrals to services per legal and regulatory requirements, such as CPS, APS, law enforcement, etc.
Provide resources and direction to those patients in crisis situations.
Assist members in access to additional benefits within their health plan benefits and also to external benefits, such as MediCal, IHSS, State, Federal Disability programs, Community and other programs as appropriate.
Consult with patients as part of the discharge clinic and diabetes care teams.
Screen patients through medical record review and patient/family interview as referred from home palliative programs, discharge clinics and CM/PCP referrals
Utilizing motivational techniques, work to engage attributed members in the care management programs.
Assist members in accessing care providers according to their healthcare needs.
Work to encourage members to select providers within the local network in order to maximize continuity and collaboration between providers.
Use rapport building strategies to engage members in their treatment plans and goals of care.