POSITION SUMMARY:

The Social Work Case Manager is a core member of the intensive in-home case management services offered by the Home Health program.  Under the direction of the Director of Case Management, the Social Work Case Manager works collaboratively with an RN Case Manager partner providing the psychosocial case management focus to a caseload of up to 45 clients in order to maintain quality healthcare across the service continuum, decrease fragmentation of care, assist the client to remain engaged in HIV care and treatment, maximize health outcomes, reduce HIV transmission, and remain independent in their home or community-based setting.  This is a temporary position, with the possibility of full employment. 

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Receive inquiries regarding participation in the Home Health Program; explain conditions of participation and obtain informed consent from clients to participate in the Home Health Program.
• Collaborate with the Nurse Case Manager to assess whether the client is eligible for either the Home-Based Case Management Program or Medi-Cal Waiver program via intake interviews including obtaining historical and current psychosocial information.   Consult with the Nurse Case Manager in setting the client’s Cognitive Functional Assessment score.
• Perform initial comprehensive psychosocial assessment and ongoing reassessments, including an assessment of the client’s psychosocial, legal, financial, social support system and medical status.  Document the results of the assessments in the prescribed format. 
• Develop the initial service plan in collaboration with the Nurse Case Manager.  Facilitate involvement of the client or client’s legal representative or family in the development and revisions of the service plan, as possible.
• Participate fully in case management activities within his/her area of expertise, and in collaboration with the assigned Nurse Case Manager.
• Document results of the intake and subsequent contacts in the electronic health record and in written form.
• Consult with the client’s attending physician, primary care practitioner and/or other medical providers as needed to coordinate treatment plans and advocate for the client as necessary.
• Identify those services available to the client and coordinate services and/or make appropriate referrals as required in the service plan.
• Document services needed but not available at APLA and refer to other community based organizations.
• Monitor the service plan regularly, in cooperation with the Nurse Case Manager. Document the service plan review per protocols.
• Negotiate with subcontracted psychotherapy service providers when services have either not been provided as requested, or have been inadequately provided.
• Maintain timely and appropriate contact (as specified in the Joint AIDS Case Management Protocols/County Contracts) with assigned clients.  Clients are to be re-assessed in-person minimally every 90 to 180 days, with at least monthly phone contacts to review services and to monitor client’s well-being. 
• Identify and follow up on instances of abuse, neglect, and exploitation that bring harm or create the potential for harm to clients.
• Adhere to all applicable professional, legal, and ethical standards of clinical practice in the provision of services, including but not limited to:  mandated reporting, provision of effective services, case documentation, client confidentiality/HIPAA regulations, ensuring client safety, and maintaining professional boundaries.
• Establish working relationships with members of the client's social support systems (e.g. significant others, family members, friends, conservators, etc.), when possible.  Provide emotional and practical assistance to help them in maintaining their support to the client.
• Promote understanding of the psychosocial factors impacting persons living with HIV disease or AIDS.
• Attend case conferences and interdisciplinary treatment team meetings, present reports and collaborate with other team members, document the outcome of the team decisions in the client's chart.
• Obtain training annually on topics that address HIV/AIDS, case management, psychosocial needs, and co-morbid disorders.
• Document all actions made on a case in the specific client record in accordance with protocols.
• Accurately complete all documents in a timely manner.
• Attend unit, division, and other agency meetings as assigned.

OTHER DUTIES MAY BE ASSIGNED TO MEET BUSINESS NEEDS.

REQUIREMENTS:

Training and Experience:

Master’s degree in social work, counseling, or clinical psychology.  License as an LCSW, LMFT, or Psychologist preferred. Two years’ experience providing social work or mental health services to HIV-infected/affected populations. 

Knowledge of:

Psychosocial assessment; case management practices; HIV/AIDS, public benefits, community resources, substance abuse, psychiatric illness, home health care procedures, health care reimbursement mechanisms.  Microsoft Office suite including Word and Excel.

Ability to:

Assess biopsychosocial needs, utilize community resources, communicate effectively, participate as an effective member of an interdisciplinary team; conduct sensitive, empathetic interviews; respect the dignity of clients who may have experienced stigma or discrimination; prepare accurate, concise, comprehensive reports; maintain confidentiality of the clients being served; maintain client records in an accurate and timely manner. Demonstrate proficiency with both verbal and written skills. Meet reasonable deadlines.

WORKING CONDITIONS/PHYSICAL REQUIREMENTS:

This is primarily a field position that requires only occasional bending, reaching, stooping, lifting and moving of office materials weighing 25 pounds or less. The position requires daily use of a personal computer and requires entering, viewing, and revising text and graphics on the computer terminal and on paper. The position requires use of a personal vehicle; up to 50% of the time position will involve driving throughout Los Angeles County, getting into and out of one’s vehicle and meeting with clients in their homes.  Some stair climbing and walking uphill is required in getting from one’s vehicle to some clients’ homes.  The work schedule is a 4-day 10 hour workweek, but final work schedule will be agreed upon by case management team, with Program Manger’s approval.  There is no evening, weekend, holiday, or after-hours on-call work required.

SPECIAL REQUIREMENTS:

Must possess a valid California driver’s license; proof of auto liability insurance; and have the use of a personal vehicle for work related purposes. COVID-19  and Booster or Medical/ Religious Exemption required.

Equal Opportunity Employer: minority/female/disability/veteran.