Bilingual Spanish Medical Social Worker - MSW / LCSW (Conduct Home Visits in Las Vegas / Henderson, NV)

Overview of the Role:

Alignment Health is seeking a proactive, organized, and compassionate bilingual Spanish social worker to join the Care Anywhere team in Las Vegas, NV or Henderson, NV.  As a social worker, you get to assess and evaluate members’ needs and requirements to achieve and / or maintain their health. You will be providing field, virtual, and telephone visits while guiding members and their families toward and facilitating interaction with resources appropriate for their care and well-being. You will also work in collaboration with a multi-disciplinary team, employing a variety of strategies, and techniques to enable a member to manage their physical, environmental and psycho-social health issues.

If you are seeking an opportunity to learn and grow, be a part of a collaborative team, and positively impact the lives of seniors – we are looking for YOU!

Responsibilities:

• Conduct telephonic social work outreach to assigned members to assess health, environment, mental health, nutrition, functionality, decline, and psycho-social areas of concerns by conducting a Social Work assessment.
• Coach and problem solve with member to identify and address specific goal(s) to support health and behavior change in response to assessments
• Document social work Interventions and goals in the EMR. Submit documentation into the medical record within (2) business days of face-to-face field visits seeing the member, and within the same day care is provided for telephonic and virtual visits, in adherence to the department’s documentation timeline requirement.
• Promotes the value of Health Care Advanced Directive and documents discussion of member preferences.
• Chart member encounters in a thorough and timely manner.
• Provide appropriate interventions to optimize health and well-being. Interventions may include education, the coordination of community- based support services, supportive counseling for mental health conditions, care navigation, advanced care and end of life planning
• Collaborate with other members of the interdisciplinary team.
• Chart members’ treatments and progress in accordance with state regulations and department procedures.
• Makes referrals to case manager, as appropriate, and / or refers members’ family to community support services and resources.
• Provide home assessment to high-risk members and develop an individual care plan
• Learn and understand the clinical program design, program monitoring, and reporting to best serve members and implement the model of care.
• Perform a full range of clinical social worker procedures in accordance with clinical privileges granted by the plan and based in accordance with social work standards of practice.
• Practice as an interdependent member of the health team and provide important components of primary health care through direct social work services, consultation, collaboration, referral, teaching, and advocacy.
• Provide direct and indirect services to both inpatients and outpatients in accordance with social work standards of practice.
• Assess and treat outpatients in individual and family modalities exercising mature professional judgment and using a wide range of social work skills to include individual and family counseling to assist patients and their families in dealing with chronic and acute diseases / injuries.
• Conduct psychosocial assessments to determine patient needs and resources (both family support and community support). Provide counseling to patients and family in matters directly related to patients’ limitations, adjustment to medical conditions, and ongoing treatment. Participate with nurses and physicians in the implementation of discharge plans, follow-up care, and transfers to other health care facilities (e.g., nursing homes, rehabilitation hospitals, etc.)
• Plan and maintain referral and coordination services of services with other agencies to provide optimal patient care.
• Provide consultation services to medical, nursing, and ancillary hospital staff regarding psychosocial issues, discharge plans, and follow-up care for patients and families.
• Provide crisis intervention services when indicated.
• Respond independently, and with various media, to appropriate community requests. Take the initiative in seeking out opportunities to present programs to meet the needs of patients / members and their families.
• Consults with hospitals and plans in the coordination of care regarding the mental health of members. Develop and maintain working relationships with community resources. Coordinate with physicians, and representatives of their service disciplines for the benefit of the members and their families. Take initiative in identifying and assessing the needs of the community and organize response