Social Worker (Home visits in Fresno)

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first.

We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community.

Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

Alignment Health is seeking a social worker to join the Care Anywhere team to conduct home / SNF visits in Fresno (4 home visits per day with mileage reimbursement) and telehealth visits for Madera and Merced.

The Social Worker assess’ and evaluates members’ needs and requirements to achieve and/or maintain their health. Guides members and their families toward and facilitate interaction with resources appropriate for their care and well-being.

Works in collaboration with a multi-disciplinary teams, employing a variety of strategies, approaches and techniques to enable a member to manage their physical, environmental and psycho-social health issues.

Schedule: Monday - Friday, 8:00 AM - 5:00 PM

General Duties / Responsibilities

1. Conducts telephonic outreach to assigned members to assess health, environment, nutrition, and psycho-social areas of concerns using a variety of assessments. a. In response to assessments, coaches and problem solves with member to identify and address specific goal(s) to support health and behavior change. b.

Provides appropriate interventions to optimize health and well-being. Interventions may include education, the coordination of community-based support services, and other resources. c. Charts member's treatments and progress in accordance with state regulations and department procedures. d.

Makes referrals to case manager, as appropriate, and/or refers member's family to community support services and resources.

2. Provides home assessment to high-risk members and develop an individual care plan

3. Collaborates with physicians in screening and evaluating members for psychotropic medications.

4. To better serve members and implement the model of care, understands the clinical program design, program monitoring and reporting.

5. Practices as an interdependent member of the health team and provides important components of primary health care through direct social work services, consultation, collaboration, referral, teaching, and advocacy.

6. Assess’ and treats 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.

7. Conducts psychosocial assessments to determine patient needs and resources (both family support and community support). Provides counseling to patient and family in matters directly related to patients’ limitation, adjustment to medical condition, and ongoing treatment. Develops and implements discharge plans, follow-up care, and transfers to other health care facilities (e. g., nursing homes, rehabilitation hospitals, etc.)

8. Provides consultation services to medical, nursing, and ancillary hospital staff regarding psychosocial issues, discharge plans, and follow-up care for patients and families.

9. Provides crisis intervention services.

10. Responds 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.

11. Consults with Hospital administration, and Plan supplying information and feedback regarding procedures and services provided by the Psychology Division.

12. Develops and maintains working relationships with community resources. Coordinate with physicians, and representatives of their service disciplines for the benefit of the member and their families. Take initiative in identifying and assessing the needs of the community and organize responses to address those needs.

13. Interfaces with the RN Case Manager(s) and the Interdisciplinary Team (IDT) in the development and implementation of the Case Management Program (CMP).

14. Integrates social work case management and nurse case management as a team.

Job Requirements

Experience:

• Required: Minimum 5 years of experience in care management, assessment, long term member/patient care management or community based resource delivery. 2 year experience with vulnerable adults or older adult population. 1 year experience with motivational interviewing-Ability to apply Motivational Interviewing and Appreciative Inquiry.

Education:

• Required: Master’s Degree in Social Work (MSW)

Training:

• Preferred: Crisis intervention training

Specialized Skills:

• Required:

Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.

Intermediate to advanced computer skills and experience with Microsoft Word and Excel.

Skill to understand current and potential needs of members to take appropriate action in order to support member in health and well-being changes.

Skill in building trust in partnership with member/client/patient.

Basic knowledge of complex care management and care management principles.

Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;

Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly

Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.

Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.

Report Analysis Skills: Comprehend and analyze statistical reports.

Licensure

Required

Current, valid, unrestricted California Driver's License and reliable transportation.

Preferred

Valid unrestricted Social Worker license (LCSW)

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Essential Physical Functions

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1 While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

2 The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Pay Range: $77,905.00 - $116,858.00

Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

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