The Social Worker II serves as an expert resource to the Care Management Team, Brown and Toland Physicians, providers, patients’ and patients’ families in a collaborative process evidenced by assessing, planning, and facilitation of options and services to meet individuals’ complex biomedical and psychosocial needs. Also provides support to in-patient nursing staff for appropriate discharge planning and provides quality oversight of the work of non-licensed Social Work staff. May also provide home visits to help coordinate in-home care management support.
Assists The Care Management Team, Providers and Physicians in assessing and meeting the needs of patients and families experiencing complex biomedical and psychosocial needs impacting their health status. This work may occur telephonically in the office or in-person at local facilities or in-home.
Take a lead role in interviewing, assessing and diagnosing individuals with complex behavioral health needs and developing integrated/ individualized behavioral health treatment goals as part of a comprehensive care plan.
Provides guidance to non-licensed social work staff, and other team members regarding particularly complex behavioral health issues and recommending strategies and techniques to help staff alleviate patient mental and emotional distress.
May conduct group or individual therapy depending on program needs identified by Medical Services leadership.
Provides appropriate and timely documentation regarding complex biomedical and psychosocial issues.
Manage Behavioral Health referrals and provide navigation to patients and physicians to access appropriate behavioral healthcare services.
Collaborate in discharge planning for a patient’s safe transition to home or to another level of care in collaboration with the patient, the patients’ family and the health care delivery team.
Collaborates with the patients’, families and Care Management Team, Coordinators, Providers and Physicians in the implementation of a comprehensive plan of care.
Provides guidance with end of life decision making, facilitating communication between patients’, families, providers, the Care Management Team and Physicians, supporting a compassionate approach to the process of transitioning to palliative care and hospice.
Develops and implements efficient processes for referring patients and families to Federal, State, and County assistance programs.
Provides ongoing education to Medical Services Department and Physicians on locally available community resources and develops and maintains effective relationships with staff in key community resource agencies.
Actively participates in team meetings and selected case conferences to provide assistance in identifying and resolving biomedical and psychosocial needs of patients and families.
Works with staff in Marketing and Communication on projects to enhance Brown and Toland Physicians visibility with employers and key community agencies.
Consistently follows Brown and Toland Physicians policies and procedures and assists in the development of policies specifically related to Social Work functions/roles and behavioral health services.
Provide written documentation/reports to the Director of Clinical Operations. Operations Manager, or other members of the Medical Management team as requested, routine and/or ad hoc. Analyze necessary data to support informational findings.
REQUIRED EXPERIENCE AND SKILLS:
Minimum of five years experience in social services support to clients, preferably in a health care setting
Excellent verbal and written communication skills
Self-motivated with effective critical thinking skills
Ability to work collaboratively as part of the clinical team
Thorough knowledge of managed care, third party payers, regulatory and accreditation requirements, and government entitlement programs
Excellent telephonic etiquette
Ability to multi-task and set priorities
Ability to work independently
Ability to use all software programs effectively, including MS Suite of services
Valid and current California Driver’s License and automobile insurance
Knowledge of Behavioral Health Issues
Comprehensive collaboration experience in a team environment
Must have a Masters Degree in Social Work and LCSW
Brown & Toland, based in San Francisco, is an independent practice association (IPA) of more than 850 community physicians serving...