Provide psychosocial assessments of patients and caregivers that:
Support effective planning to improve care
Identify patient/family issues that may negatively affect the team’s treatment recommendations
Determine how the issues may impact ability to follow the treatment plan
Offer specific interventions that improve outcomes, including but not limited to emotional, mental health, and substance abuse treatment.
Develop and implement a comprehensive psychosocial treatment plan utilizing appropriate clinical social work treatments and interventions. Interventions may include:
Coordinating appropriate services, such as Home Health or Hospice care, appropriate other levels of care such as SNF, Board and Care, Care Givers at home.
Education of patients, family members, and care givers around issues related to adaptation to the patient’s diagnosis, illness, treatment and or life situation.
Participation in multi-disciplinary health care teams and representing the social work perspective with the patient, family and care providers.
Educate care team and others regarding the role and responsibilities of the Social Worker and help staff in identifying patients needing a Social Work Intervention.
Assist in advance care planning and completion of Advance Directives and POLST. Coordinate symptom management and/or end-of-life services.
Assessment and referral for Medi-Cal and/or other insurance eligibility based on new entitlements and referral for SSI and or SSDI as needed or within scope of care definitions as indicated.
Maintain a working knowledge of relevant medical/legal issues that may have an impact on the care of the patient, e.g. advance directives, and reporting for elder and/or child abuse. Provision of consultative services to other health care professionals as indicated.
Maintain a working knowledge and liaison relationship with community agencies and resources. Determine and coordinate application of Health Plan, Medicare and Medi-Cal benefits. Maintain client privacy, safety, confidentiality, and advocacy while adhering to ethical, legal, regulatory and accreditation standards.
Potential travel to visit patients in Skilled Nursing Facilities and in PCP offices.
Assist in managing behavioral and /or substance abuse issues. When appropriate provide training to other health care professionals on the team.
Support screening, identification and management of victims of abuse, neglect, domestic violence, including elder abuse. Provide support and training as indicated to other health care professionals.
Maintain a working knowledge of relevant medical/legal issues that impact on patient care, e.g., advance directives, and reporting for child and elder abuse. Maintain working knowledge of and liaison with community agencies and resources. Determine application of Health Plan, Medicare & MediCal benefits. Maintain client privacy, safety, confidentiality, and advocacy while adhering to ethical, legal, regulatory and accreditation standards.
Contribute to development and maintenance of Social Work and other department procedure/policy standards.
Support the interdisciplinary team approach to ensure effective resource utilization, as well as quality and cost-effective outcomes.
Contribute to community resource database.
Document activities in the appropriate HPMG documentation system.
Utilize existing reports and systems to identify and monitor utilization resource patterns and facilitate needed care coordination.
Refer to various departments for supportive interventions, i.e., Contracting, Provider Services, CAPC, etc.
Support provider education.
Attend and participate in in-service programs and conferences that support practice of care management.
Perform other duties as assigned.
Licensed Clinical Social Worker (required)
2-4 years social work experience within the last 5 years (MSW fieldwork not included), preferably in a managed care environment
A wide variety of illnesses/conditions & resulting needs
Crisis, grief & family counseling
A wide variety of oncological diagnosis & resulting coping & other psychosocial issues.
Working w/ elderly & other diagnosed w/ a wide variety of dementia as well as community resources to meet needs of this population.
Experience providing clinical services to patients w/ multiple ongoing health conditions. Works w/ nursing to insure patients are as active & healthy as possible
Initiating/participating in end-of-life discussions w/ patients & families, assisting in hospice referrals, holding family conferences, home visits & advanced care planning
Experience in crisis intervention, counseling & referral services to psychiatrically and/or socially high risk members
Demonstrated ability to work on multidisciplinary team
Must have solid psychosocial assessment skills
Knowledge of chronic & acute disease; how it impacts patient/family functioning
Demonstrated excellent oral/telephone & written communication skills
Must be computer-literate &, preferably, experienced in automated clinical info systems
Demonstrated ability to function independently as a collaborative, supportive team member
Must be able to master detailed & complex info regarding benefits & coordination of care
Experience with managed care delivery required.
Optimum organizational skills with ability to meet both expected and unexpected time frames.
Ability to coordinate effectively with a variety of customers including client, providers, office staff, health plans, internal department, community resources, and peers.
Ability to work independently with self-initiative and discipline.
Who We Are
?Your health. It’s our mission.
Hill Physicians offers our members and the communities we serve some of the most advanced and comprehensive healthcare in northern California – through a network of primary care physicians, specialists and other healthcare providers consistently rated among the best in California.
It’s about your p...hysician and your quality of care. From San Francisco and the East Bay to Sacramento and Stockton, our physicians are dedicated to providing the best quality of care – care that our members can trust and rely on. In fact, in terms of clinical outcomes and patient satisfaction, Hill Physicians is consistently rated among the best of California’s 200 medical groups by the California Office of the Patient Advocate.
It’s about choice and consistency of care. With almost 4,000 physicians and other healthcare providers, we are the largest network of independent physicians in northern California. And, we are among the oldest medical groups. Founded in 1984, Hill Physicians has a long history as one of the nation’s leaders in managed healthcare.