The Health Care Quality and Affordability team is made up of about 1,000 doctors, nurses, pharmacists, strategists, industry experts and innovators with a single vision – to transform the delivery of health care. Every day, we work together to improve the quality of patient care for our members while lowering health Care costs to ensure all Californians have access to the care they deserve.
How do we do it? Through partnership, innovation, and thought leadership.
We continue to expand our network of providers to ensure state-wide access to care. We evaluate analytic and digital health tools that simplify care delivery while improving member health status, health care quality and affordability as well as member and provider experience. We provide high-touch services to members from experienced clinical teams. You’ll also find us collaborating with our federal and state legislative officials to help shape policy to advance our Blue Shield mission.
The care management social worker will report to the senior manager of care management and services to support the department's mission, helping patients maintain health and wellness in the outpatient setting. The selected candidate is responsible for developing, planning, implementing, and evaluating all social service-related interventions for the Case Management Department.
Specifically, this position will be responsible for identifying patients who have psychosocial needs. The Ambulatory Case Manager/Social Worker is also available to physicians and nurse case managers as a dyad partner for those patients with complex psychosocial needs. The position demands an intensive focus on crisis intervention and counseling, problem-solving and conflict resolution, patient and family management, interdisciplinary collaboration, biopsychosocial assessments, education, advocacy, and community resource linkages.
The care management social worker will provide support to individuals including, but are not limited to, high risk and frail patients, seniors, and those with chronic and terminal medical conditions across Medi-Cal, Medicare, Duals (DSNP, CalMediConnect) and Commercial lines of business.
The selected candidate will also function as the subject matter expert on social services and represent care management initiatives. The best-qualified candidate will act as a liaison between other business units within Blue Shield to bolster care management social work knowledge on community resources, best practices and promote a holistic and integrated medical care management approach.
The care management social worker applies detailed knowledge of Blue Shield of California (BSC) established medical/departmental policies, clinical practice guidelines, community resources, contracting, and community care standards to each case. Care management care plans typically last three months per member/patient; reinforce pillars of care that include but are not limited to increasing quality of patient care and access while improving member satisfaction.
The care management social worker must have an extensive background in the care management operations and a solid knowledge of community resources, Medi-Cal and Medicare, Duals (D-SNP, CalMediConnect) benefits, best practices, and the holistic and integrated high-tech and high-touch approach to medical care management.
- Daily collaboration and patient care planning with RN Care Manager and Clinical Service Coordinator (CSC), who are members of the population pod in a triad model of care.
- Assigned as Social Worker in partnership with other CM-led pods.
- Daily morning and end of the day huddles with RN and CSC in preparation for planned patient activities/outreach for the next day.
- Patient pods are CM led and at-risk population-based.
- Evaluates and implements a high-tech, high- touch intervention for patients with psycho/social issues. With a focus on seniors, catastrophic, and chronic patients.
- Utilization of depression Screening tools for selected populations.
- Develops reports for outcome measurement.
- Implementation: triage patients with the case management team; assist in coordinating patient care delivery, including DPA; document pertinent information in the case management system and communicate to the team.
- Evaluation: evaluate caseload daily and assess achievement of long- and short-term goals; modify goals with providers and case management based upon patient outcomes; compile and present statistics and reports relating to patient outcomes; document findings in the patient's chart or case management system
- Communication: provide follow up and outcome communication to the referral source, i.e., PCP, family member, case manager, home health personnel, community social worker, Health Plan, and other.
- Act as social services liaison for the department and physician offices.
- Complex discharge planning.
- Referral to agencies that provide supportive services to fragile patients.
- Assists in the arrangement of community resources (i.e., meals on wheels, transportation services, adult daycare, and info-line).
- Assists in long term planning for patients transitioning to an institutionalized setting.
- Provides alternatives for patients requiring specific services while lacking insurance coverage.
- Acts as liaison to Population Health department regarding chronic disease state management programs.
- Facilitates as liaison to the Member Services and QI departments to address any ongoing case management issues or concerns as referred.
- Strong clinical documentation skills, independent problem identification, and resolution skills.
- Strong verbal and written communication and negotiation skills.
- Works on projects with minimal supervision.
- Demonstrates cultural competence to work effectively, respectfully, and sensitively within the client's cultural context.
- Member Advocacy: Advocates understanding and respect for the beliefs, value system, and decisions of the client. Recognizes the client's right to self-determination as it relates to the ethical principle of autonomy, including the client/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare team.
- Assists with precepting responsibilities for new hires and auditing efforts.
Knowledge, Experience and Education
- A minimum of a master's degree in social work or social welfare )from a regionally accredited college or university.
- A minimum of 3 years' experience in an inpatient, outpatient, or managed care environment.
- A minimum of 5 years' combined clinical social work practice in the hospital, outpatient, or managed care setting.
- Licensure as Clinical Social Worker (LCSW) in California.
- Certified Case Manager (CCM) or related board certification from a nationally recognized entity, i.e., ACM, Palliative Care.
- Health insurance/managed care experience (Commercial, Medicare, and Medi-Cal).
- Lean methodology.
- Excellent presentation and procedure-writing skills.
- Excellent communication skills.
- Transitions of care.
- Community resources and advocacy.
- Practice integration in a triad model of care.