D-SNP Social Worker Location: Candidates for this position must reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties). Description: The D-SNP Social Worker within the Care Management team helps our dual-eligible (D-SNP) members by addressing psychosocial and social-determinant needs and coordinating services across medical, behavioral health, LTSS, and community programs. What You Will Do: Psychosocial Assessment and Care Planning: Conduct member-centered psychosocial assessments and reassessments, addressing behavioral health, functional status, caregiver needs, rehabilitation, and environmental/SDOH concerns. Evaluate holistically to identify functional limitations that affect independent living and safety. Develop and update individualized, person-centered care plans with the member/caregiver; set measurable goals and review after significant events (e.g., hospitalization). Recommend strategies to improve function, independence, and caregiver support. Participate in Interdisciplinary Care Team (ICT) activities, share updates, and ensure aligned follow-through on care plan goals. Consult with the Nurse Care Manager on medical issues; collaborate with pharmacists, behavioral health clinicians, PCPs, specialists, and community partners. Care Coordination and Transitions Support: Based on assessment findings, arrange, coordinate, and monitor services from medical, behavioral health, LTSS, and community providers. Facilitate warm handoffs and coordinate services during transitions (hospital - SNF - home/ALF), supporting follow-up appointments and community service linkages to reduce gaps in care. Conduct home visits as applicable to assess the living environment, safety risks, caregiver strain, and resource needs; document findings and actions. Refer to specialized programs as indicated (e.g., CCS, TCRC, County Behavioral Health/ADMHS, Public Health) and to complex medical case management when needs are primarily medical. Manage an active caseload, prioritize by risk/need, and deliver interventions within role scope. Resource Navigation and Advocacy: Identify and address home environment needs, including meal delivery, transportation, counseling referrals, in-home skilled/non-skilled services, and alternative living options. Connect members to benefits and programs (e.g., IHSS, HCBS/CBAS, housing and food support, transportation, utility assistance) and assist with applications and appointments as appropriate. Provide brief supportive interventions (e.g., problem-solving, motivational engagement) and crisis resource linkages; escalate safety concerns per policy. Supportive Interventions and Documentation: Document timely and accurately in the care-management system: assessments, care plans, outreach, referrals, ICT updates, and outcomes. Maintain HIPAA/confidentiality and follow all privacy, consent, and release-of-information procedures. Meet required turnaround times for outreach, documentation, and follow-up. Uphold high ethical standards; participate in continuing education to maintain current knowledge. Perform other duties as assigned. You Will Be Successful If: Demonstrates the ability to build trust and rapport with members and caregivers using plain language, cultural sensitivity, and respect for linguistic and individual differences. Proficient in conducting comprehensive assessments and reassessments, including behavioral health, ADLs/IADLs, caregiver capacity, and social/environmental factors; recognizes and responds to safety and functional risks. Develops and updates individualized, person-centered care plans with measurable goals; revises plans after significant events (e.g., hospitalization). Arranges, coordinates, and tracks services across medical, behavioral health, LTSS, and community providers; follows up to confirm linkage and progress toward goals. Working knowledge of local/community resources and programs (e.g., IHSS, HCBS/CBAS, housing/food/transportation supports, County Public Health/Behavioral Health, CCS, TCRC) and how to refer/connect with members. Collaborates effectively with Nurse Care Managers, pharmacists, behavioral health clinicians, PCPs/specialists, and community partners; participates in ICT activities and closes the loop on action items. Supports discharge planning, warm handoffs, appointment scheduling, and follow-up to reduce gaps when members move between settings (hospital - SNF - home/ALF). Able to conduct home visits as applicable, observes and documents environmental risks, caregiver strain, and unmet needs; escalates safety concerns per policy. Provides short, goal-focused support (problem-solving, engagement, crisis resource linkage) within role scope; refers to clinical specialists when indicated. Documents assessments, care plans, outreach, referrals, ICT updates, and outcomes accurately and on time in the care-management system; maintains organized records. Adheres to HIPAA and confidentiality requirements; maintains professional boundaries and high ethical standards. Manages an active caseload; prioritizes by risk/need; meets required turnaround times for outreach, documentation, and follow-up. Identifies barriers, resolves within scope, and escalates to licensed staff/supervisors as needed; recommends strategies to improve function and independence. Dependable, collaborative, responsive in communications; participates in required trainings/meetings and integrates feedback to improve practice. What You Will Bring: An active, unrestricted Licensed Clinical Social Worker (LCSW) license may substitute with 5 years’ work experience. Master’s degree in social work, Clinical Psychology, or Psychology is required. A concentration in Gerontology, Pediatrics, Public Health, Substance Abuse, Mental Health, or other related fields is preferred. A minimum of five years of clinical work experience in the specified field is required. Experience managing medically complex, high-risk, or vulnerable adult populations. Prior experience conducting comprehensive assessments and developing person-centered care plans. Knowledge of managed care issues, including Medi-Cal and Medicare benefits, contract limitations, delivery and reimbursement systems, and medical management activities. Bilingual in Spanish preferred. About Impresiv Health: Impresiv Health is a healthcare consulting partner specializing in clinical
Read Less
