HRTMS Job Description Management

JOB PURPOSE

The Social Worker Lead (SWL) provides direct case management services to On Lok participants and acts as the subject matter expert (SME) providing department leadership including administration, mentorship, and consultation at an appointed center. The primary role of the SWL is to assist participants and their family/caregivers to cope with the social and emotional issues and practical arrangements related to maintaining their independence. Under the supervision of the Regional Social Work Manager, with additional oversight from the Center Director, the SWL serves as an integral member of the Interdisciplinary (IDT) team providing assessments, coordination, treatment planning, information and referral to community resources and other social work services to meet the complex needs of participants and their families.

ROLES AND RESPONSIBILITIES CLINICAL PRACTICES & CASE MANAGEMENT

• Utilize independent judgement and discretion to provide case management to a panel of participants
• Conduct initial and routine psychosocial assessments on new and existing participants in order to develop, implement and update individualized care plans and interventions.
• Partner with caregivers and support system to develop care plan and deliver services.
• Identify risks and other psychosocial problems.
• Identify service needs of each participant, advocate, refer, coordinate and follow up in a timely fashion.
• Provide individual counseling.
• Facilitate family conferences.
• Reach out to the larger community to meet participants' specific needs. Act as the main liaison between participants, caregivers, the team, and the community.
• Assess needs and complete discharge planning when a participant dis-enrolls from On Lok.
• Facilitate participant and/or caregiver groups and participate in special events such as weekend caregiver workshops.
• May review and verify the findings of assessments conducted by non-MSW social workers.

INTERDISCIPLINARY TEAM MEMBER

• Act as the main liaison between participants, caregivers, the team, and the community.
• Work with relevant departments such as Health Plan and other community agencies e.

g.

RCFE, NF, DAAS

(Department of Adult and Aging Services).

• Adhere to all ethical and legal standards of social work practices.
• Comply with all On Lok policies & procedures including but not limited to PACE, safety, and confidentiality requirements.
• Fulfill all documentation requirements in a timely and accurate manner.
• Actively participate in team meetings, advocate for the needs of participants and their caregivers, compromise differences among team members, support and carry out team plans.
• Incorporate the Healthcare Hospitality

G.R.E.A.T.

Practices for 5-Star service.

• All other reasonably related duties as assigned.

LEAD RESPONSIBILITIES

• Is the subject matter expert (SME) of the electronic health record for the social work department.
• Assist in the review and update of department and IDT policies and procedures.
• Assist in the orientation and training for new Social Workers and Social Work Aides.
• Assist in overseeing competencies for social workers.
• Assist in developing, maintaining and facilitating relationships with other clinical disciplines and non-clinical staff in order to deliver quality participant care at appointed center.
• Assist with developing the social work education program.
• Primary point-person for social work issues at appointed center.
• Assist in providing support to Social Workers at appointed center.
• Assist in the continuous quality improvement of social work services and efficiency of systems.
• Actively participates and contributes to the Social Work Leadership Council (SWLC) activities.
• Assist with developing the social work continuing education program.
• Contribute additional clinical and/or workflow process perspective regarding participant care to Center Director in support of the MSW and SWA, as requested.
• Assist in coordinating student placements (interns) including training, oversight, and evaluations.
• Actively participate as a change agent in On Lok's organizational vision and mission.
• All other reasonably related duties as assigned.

REQUIRED QUALIFICATIONS

Education Education Level Education Details Master's Degree Graduate of an accredited college with a MSW degree Work Experience Experience Experience Details Three years' experience in social work. Minimum two years' experience in the geriatric field and/or with a frail population. At least one year of leadership experience. Knowledge, Skills and Abilities KSAs

• Experience or ability in working with a diverse population.
• Experience working within the framework of an interdisciplinary team.
• Good interpersonal skills including ability to work cooperatively on an interdisciplinary team.
• Highly organized and has the ability to prioritize and work under extreme pressure.
• Excellent written and verbal communication skills.
• Flexible, creative problem solver.
• Computer literate and basic knowledge of Microsoft Office.
• Bilingual ability may be required for specific assignments.
• Clinical Practices and Case Management.

Licenses and Certifications Enter Licenses/Certifications Licenses/Certification Details Time Frame Clinical\MSW - Medical Social Worker Valid Social Worker license in California.

PREFERRED QUALIFICATIONS

Work Experience (Preferred) Experience Experience Details Minimum two years case management experience in geriatric field. Minimum two years health care related experience. Five or more years' experience in social work. Knowledge, Skills and Abilities (Preferred) KSAs

• Experience with electronic health record system.