Local Contract Social Work - Licensed Clinical Social Worker
Ventura, CA
TNAA TotalMed RN
5x8 hrs, Days
Referral Bonus

MINIMUM QUALIFICATIONS
Required Education and Experience:
• Bilingual English/Spanish 

Master’s degree in social work or, comparable master’s degree
• 5+ years of relevant experience (e.g., Medical Social Work, Hospice, Home Health, Care Management).
• Experience working with Medicare or vulnerable populations.
• Knowledge of community resources, behavioral health systems, and long-term care.

JOB DUTIES:

• Completes telephonic calls and in-person field visits to conduct the CICM assessment with DSNP members. Works with the member to develop an individualized care plan (ICP) and with interdisciplinary care team (ICT) to develop and assess health interventions on-going. 
• Develop individualized care plan (ICP) with person centered approach jointly with the members, PCP and other providers as needed to address identified member problems using evidence-based goals and interventions.
• Participate in interdisciplinary care team (ICT) meetings and be able to present complex medical cases before the team.
• Work collaboratively with health plan’s providers, particularly member’s primary care providers and specialists, to provide highly coordinated and often specialized care including but not limited to palliative care, county behavioral health, CBAS, and LTSS providers.
• Responsible for the time sensitive processes for initiating cases, managing referrals to the department, appropriate documentation, routing of information, performing computer data input, faxing, emailing, filing of confidential member information, and maintaining logs of activity, etc. 
• Conducts telephonic outreach calls to members/caregivers regularly and evaluates and documents their progress towards their healthcare goals. Sets up provider/specialist appointments and follow up on treatment plans. Assess changes in member status that warrant additional assessments or ICP review and updates.
• Transitional Care Services: Provides member and caregiver support, coordination, education and advocacy during all in-patient care stays and transitions between care settings ultimately to home through the entire episode of care.  
• Engages members as appropriate to participate in the CM/Disease Management and other specialized care programs by reaching out and promoting the programs to address member’s unmet needs. 
• Review medical records and community assessments for member history and care planning.
• Coordinate care to ensure a seamless experience for the members with non-duplication of services.
• Promoting medication compliance through encouraging medication reconciliation by member’s PCP per initial assessments and transitions of care.