Social Work Case Manager

Committed to Our Community in the Heart of the Redwoods. Removing Barriers to Healthcare Access

DNCHC Del Norte Community Health Center

A Social Work Case Manager (SWCM) at Open Door Community Health Centers (ODCHC) provides integrated, supportive and enabling services to health center patients. The SWCM collaborates with an interdisciplinary care team to ensure continuity of care and assist patients in accessing services and utilizing resources to support their medical, psychological, and socioeconomic needs. The SWCM identifies and addresses a variety of non-clinical social determinants of health (SDoH) to promote positive health outcomes and reduce health inequities. The SWCM is dedicated to serving marginalized or otherwise underserved populations with lowest access to resources in our community.

Compensation Range:

$29.75-$34.43

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Assists patients in navigating the social determinants of health (SDoH) in order to provide effective interventions, improve health outcomes, and increase accessibility to resources.
• Maintains knowledge of and effective relationships with community resources, benefit programs and social service providers. Provides direct assistance with eligibility, referral, documentation, navigation, education, enrollment and follow-up when necessary.
• Assesses the biopsychosocial needs of each patient. Identifies individual barriers, strengths, and areas of need to formulate an individualized effective case management treatment plan and implementation strategies. Collaborates with patient and care teams to develop a plan to overcome obstacles and find solutions.
• Meets regularly with patients. Utilizes proactive and flexible delivery of evidence-based approaches. Employs strategies to engage patients and families in achieving goals and optimizing health.
• Manages complex cases and ensures services across the continuum of care.
• Identifies and facilitates appropriate referrals to alcohol and drug programs, disability services, employment & training programs, mental health providers, housing services, family resources transportation, long-term care planning, social services, resources for food and financial security, county, state, and federal programs, and other community sources of support based on patient need.
• Knowledgeable in de-escalation techniques, crisis intervention, trauma response, safety planning.
• Practices a harm reduction, strengths-based, and informed consent approach.
• Participates and assists in facilitation of peer support and educational groups within internal case management, behavioral health, and substance use programs as directed.
• Liaises with internal and external programs or agencies to promote interagency collaboration.
• Participates in case conferences with primary care teams, behavioral health clinicians, discipline-specific supervisors and other case managers for feedback, education, and support. Enables consultation with interdisciplinary providers such as psychiatry, medication assisted treatment, intensive outpatient nurse case management and other embedded programs as needed.
• Meets standards for referrals, tracking, and reporting set by department. Participates in quality improvement and risk management activities.
• Actively participates in program development, planning, implementation and evaluation.
• Monitors systemic barriers and access to care issues. Communicates recommendations to supervisor and clinic leadership on areas for future attention.
• Contributes positively to the efficiency, accessibility, productivity, quality, safety, compassion and professionalism of the work setting.
• Other duties and responsibilities as identified and assigned by supervisor.

QUALIFICATIONS AND EXPECTATIONS:

• Strong interpersonal skills and the ability to establish constructive professional working relationships among a diverse workforce.
• Effective active listening, motivational interviewing, emotional intelligence, cultural humility, and critical thinking skills to engage a diverse population of patients and families.
• Ability to advocate for patients, encourage independence, and assist in development of skills to manage challenges and make healthy decisions to support mutual goals. Solutions oriented with a creative problem-solving approach.
• Knowledgeable of the effects of trauma and how it can impact families experiencing poverty, food insecurity, substance use problems, housing insecurity, and other SDoH. Familiar with evidence-based practices and patient-centered care such as trauma-informed, resilience-oriented framework.
• Works well under pressure with minimal supervision. Excellent time management and organizational skills. Flexible and able to