Support MCMG clinics and GNP practices as needed for social work needs.
Perform assessments and develop care plans as needed in the Electronic Medical Record for social work cases.
Collaborate with and support the clinical case management team.
Role requires work time both in a centralized office. within Provider clinics and in the home in specific warranted circumstances and per standard work guidelines
Contribute as needed to process design/redesign.
Provide resources in support of member needs.
As a mandated reporter, submit referrals to services per legal and regulatory requirements, such as CPS, APS, law enforcement, etc.
Provide resources and direction to those patients in crisis situations.
Assist members in access to additional benefits within their health plan benefits and also to external benefits, such as MediCal, IHSS, State, Federal Disability programs, Community and other programs as appropriate.
Consult with patients as part of the discharge clinic and diabetes care teams.
Screen patients through medical record review and patient/family interview as referred from home palliative programs, discharge clinics and CM/PCP referrals
Utilizing motivational techniques, work to engage attributed members in the care management programs.
Assist members in accessing care providers according to their healthcare needs.
Work to encourage members to select providers within the local network in order to maximize continuity and collaboration between providers.
Use rapport building strategies to engage members in their treatment plans and goals of care.