MSW Social Worker

Position Summary:

Under the direction of Manager, Outpatient Services Los Angeles and collaborating closely with the RMG social work department, Case management, Cal-MediConnect and Medi-Cal teams the Los Angeles Region Social Worker is responsible for assisting in the successful implementation of the Home discharge visit program and social work services for LA Region. This program is designed to provide individualized assessment and care management to Los Angeles Region members who are at high risk for preadmissions, readmissions and for members at risk for complex hospitalizations and/or long term health management needs. The Los Angeles Region Social Worker will provide in-depth psychosocial assessment of Los Angeles Region members through home visits and develop care plan in collaboration with the post discharge visit program personnel and other contracted health care practitioners. In addition, the Los Angeles Region Social Worker will provide knowledge, expertise, resources that are specific to Los Angeles Region members as well as information and referrals to community resources and services; and benefits independent of product line.

The goal of Post discharge visit Program is to establish early identification and focused care coordination of high risk members at risk for readmissions and complications related to identify risk factors and to educate and facilitate appropriate services for the member. To this end, the Los Angeles Region Social Worker will collaborate closely with the other disciplines and programs to effectively manage Los Angeles Region members to assure that appropriate level-of-care is provided, to prevent member re-admissions and ensure that the member’s medical, environmental and psychosocial needs are met.

Essential Duties and Responsibilities include the following:

The Los Angeles Region Social Worker is responsible, along with other members of Los Angeles Region Management Team, for contributing to the clinical, quality, financial and patient satisfaction outcomes of Regal Medical Group. Provide assistance to members and their families in the form of social services guidance, resource referral, and crisis intervention as required.

Interpret psychosocial implications of illness to attending Providers and staff as needed. Capable of being independent with decision-making within the Scope of Practice and Job Description.

Essential Duties and Responsibilities include the following:

• Working as a team member within the Los Angeles Region home visit program (HVP), CMC, Case Management, & appropriate providers and agencies to focus on care coordination of Los Angeles Region members and their families to navigate through complex care needs.
• Provide psychosocial assessment of Los Angeles Region members through home visits. Provide community resources related to clothing, housing/homeless prevention, limited financial resources, home maintenance repair, referrals, food, safety in the home, transportation, and utilities assistance.
• Develop individual treatment plans and make recommendation for Implement treatment plan using appropriate modalities, including crisis intervention, community contacts, diversion and triage.
• Collaborate with Los Angeles Region HVP, CMC and case management professionals to identify drivers of hospital admissions; reduce hospital and ER admissions.
• Attend and contribute to Interdisciplinary Care Team meetings regarding care to/for specific member, including interpreting psychosocial implications of illness to attending staff and departmental staff as needed.
• Consult upon request of clinical and/or educational staff members and/or accept referral from the regional medical director, inpatient concurrent review, case management, pharmacy or PCP office, for members needing resource information.
• Work with case managers in identifying members who are appropriate for hospice conversion or Palliative care, and assist the members and/or their families in accomplishing this process as requested.
• Assist with prescription referral source, education on how to obtain medical equipment, Advance Directives/Hospice choices, dental care referral source, non-compliant issues, and psychiatric condition interfering with medication regiment.
• Provide resources for family/Social Support; limited social support, parenting/educational skills, domestic violence, elder care, parent-child conflict, family relations issues, recreational activities, and information regarding Respite Care for caregivers.
• Assist with mental health assessment/referral sources to; individual therapy, family therapy, group therapy, anger management, behavior management, suicide prevention and alcohol/substance abuse.
• Provide evaluations (when requested) for Los Angeles Region members referred by Case Managers, Medi