The Southern California Integrated Care Network (SCICN) is a clinically integrated physician network sponsored by Dignity Health with Chapters in the greater San Bernardino area (Inland Empire) and in the Oxnard/Camarillo markets. The Social Worker is an employee of MedProVidex, a physician support organization owned by Dignity Health.
The Social Worker will participate in the implementation of integrated health services and behavioral health-based care coordination services in the Inland Empire area of Southern California. The Social Worker is a key liaison between the primary care team and behavioral health team, and will work very closely with the medical providers, behavioral health counselors, care coordinators, and patients to meet the patient’s multiple clinical and non-clinical health needs through a strength-based model. The Social Worker will be working in the community, medical offices and skilled nursing facilities.
PRINCIPLE DUTIES AND RESPONSIBILITIES
- Maintains a thorough knowledge of social work principles and practices, including case management, individual and group counseling techniques, diagnosis and treatment of mental illness.
- Performs intake, mental health screening, assessments and diagnoses for clients and creates strength-based patient care coordination plans with multi-disciplinary team members.
- Documents in the clinical record, comprehensive assessment of patient needs including barriers to timely treatment, clinical interventions, support and appropriate community resources.
- Provides clinical oversight to ensure provision of all covered services identified on the service plan; referrals to community resources as appropriate; and continuity of care between inpatient and outpatient settings; services and supports, as applicable.
- Develops and implements individual plans of treatment which assist patients and families to cope and/or restore social, emotional, financial and environmental factors which affect and/or are affected by illness.
- Assists patients to receive mental health services, health education and direct counseling services.
- Refers participants and their families to appropriate community agencies or
facilities; acts as liaison with such organizations and advocates for patients
and/or their families.
- Performs ongoing case management, which may include interacting with police, psychiatric services, and other community agencies and staff.
- Identifies medical aspects of anticipated care needs, determining when and if a Registered Nurse, Pharmacist, Diabetic Educator or Primary Care Physician is needed.
- Ensures the development and implementation of transition, discharge and aftercare plans prior to discontinuation of behavioral health services.
- Prepares complete and concise written materials, reports, and documentation.
- Assists patients in achieving compliance and improving adherence to plan of care, notifying primary care physician of issues.
- Actively participates in internal quality improvement teams and work with members proactively to drive quality improvement initiatives in accordance with the mission and strategic goals of the organization, federal and state laws and regulations, and accreditation standards, when assigned.
- Notifies supervisor of crisis situations, unusual incidents, and/or on-going problems within appropriate timelines, including reports to outside agencies, as appropriate.
- Other duties as assigned by Supervisor.