MSW Case Manager

• Management of client’s identified by Beverly Hills Fire Department, local hospitals, or others identified as appropriate referral sources.
• In-home psychosocial assessment to include medication risk screening, and identify depression, cognitive impairment, functional status, nutrition and transportation challenges, need for caregiver support, housing safety and security and a host of other social determinants of health.
• Create a care plan unique to the needs of the community member, survey available local resources, and work with the individual to implement the care plan. The care plan will work to alleviate threats to health and safety such as the fall risk of area rugs or the lack of grab bars in key places like bathrooms, and whether food and medications are available and taken properly.
• Build a rapport with the community member through visits and calls.
• Help implement fall prevention programs
• Liaison with appropriate staff members who currently provide services for the older population - such as exercise classes and transportation - and ensure that targeted and appropriate referrals are integrated into those service offerings.
• Understand and complete all requirements to be credentialed in hospital system, if applicable
• Using motivational interviewing as well as educational and transition coaching tools, conduct at least one hospital visit and prepare client for a home visit, if applicable.
• Identify support systems for the client including timeliness of primary care physician visit.
• Assist in development of a community-based referral network. Organize, coordinate and conduct reviews of community resources and social service agencies and other psychosocial referral sources for clients.
• Develop and maintain automated or manual systems and procedures to facilitate on-going program operations.
• Participates as an active team member with internal and external team members.
• Identify, assess and respond to crisis situations in a timely fashion, with appropriate interventions.
• Observe all legal, departmental, health plan and/or hospital regulations.

Partners in Care Foundation is an equal opportunity employer. We are committed to complying with all federal, state, and local laws providing equal employment opportunities, and all other employment laws and regulations. It is our intent to maintain a work environment which is free of harassment, discrimination, or retaliation because of age, race (including hair texture and protective hairstyles, such as braids, locks, and twists), color, national origin, ancestry, religion, sex, sexual orientation, pregnancy (including childbirth, lactation/breastfeeding, and related medical conditions), physical or mental disability, genetic information (including testing and characteristics, as well as those of family members), veteran status, uniformed service member status, gender, gender identity, gender expression, transgender status, arrest or conviction record, domestic violence victim status, credit history, unemployment status, caregiver status, sexual and reproductive health decisions, salary history or any other status protected by federal, state, or local laws. All qualified applicants will receive consideration for employment and reasonable accommodations may be made to enable qualified individuals to perform the essential functions of the position.

Education required: Masters degree in social work.

Experience Preferred: Minimum of one year required in healthcare and/or community-based adult focused social work.

Special Knowledge, Skills, and Abilities: Knowledge of community-based programs. Ability to work with multidisciplinary team, clients and their families in home settings.