Care Coordination Social Worker II

Location: Hybrid, in Santa Barbara, CA office as needed, only have to come into office once per quarter.

Description:
This position reports to the Care Coordination Supervisor or their designee. The Care Coordination Social Worker II (CCSW II) works closely with the Health Services team and directly with members to provide support for their psychological and social care coordination needs. With a master's degree, the CCSW II addresses both the psychosocial challenges of members and their access to government programs, social services, and community resources.

Key responsibilities of the CCSW II include, but are not limited to, communication with members, healthcare providers, and community organizations; assisting members with complex medical and psychosocial needs in transitions of care and housing resources; referring members to funding sources; and identifying community resources to help maintain members in the least restrictive environment. The CCSW II must possess in-depth psychosocial knowledge to manage a caseload that includes members of all ages across Health Services Clinical Programs, including Case Management, Care Coordination, Pediatric-Whole Child Model, Disease Management, and Behavioral Health.

What You Will Do:

• Conduct member-centered assessments and reassessments.
• Develop individualized care plans that are focused on the member and address psychosocial, rehabilitation, and environmental concerns.
• Perform follow-up contacts with members and providers to monitor needs and progress, ensuring care plans are effective and developing support systems with the member.
• Collaborate with multidisciplinary team members within the Health Services department and health plan.
• Coordinate, facilitate, and monitor services from various providers and community resources based on needs identified during assessments.
• Assist members and their families in the California Children’s Services-Whole Child Model Program (CCS/WCM) with transition planning from age 16 to 21, when members age out of CCS.
• Support members in the Disease Management Program with psychosocial needs as assigned.
• Assist with placement into alternative living arrangements, such as skilled nursing facilities (SNF), board and care, shelters, etc., as assigned.
• Assess the member as a whole and identify functional limitations that hinder independent living.
• Provide resources and referrals for crisis management.
• Collaborate and consult with Nurse Coordinators and Medical Directors on medical issues as necessary.
• Refer members to specialized programs such as TCRC, County Mental Health, and Public Health.
• Consult and cooperate with community systems to facilitate referrals, advocacy, and follow-up, focusing on achieving care plan goals.
• Conduct home visits as necessary to assess the home environment.
• Maintain an active caseload of adult and pediatric members, providing necessary interventions within areas of expertise and responsibility.
• Adhere to mandated reporting requirements.
• Maintain high ethical standards and comply with HIPAA and confidentiality regulations.
• Participate in continuing education activities and stay current in areas of expertise.
• Participate in CCS Medical Therapy Unit conferences to address psychosocial issues of members and their families.
• Perform other duties as assigned.

• Demonstrate expertise and proficiency in care management, reflecting my experience and capabilities in executing key responsibilities.
• Effectively communicate and negotiate with members, families, physicians, and healthcare providers, ensuring clear and productive interactions.
• Self-motivated with a continuous drive for learning and improving both personal and professional performance.
• Able to collaborate efficiently within cross-functional team environments.
• Possess in-depth knowledge of social resources available within health plan coverage area.
• Apply extensive psychosocial knowledge to manage members enrolled in Health Services Clinical Programs, including Case Management, Care Coordination, Pediatric-Whole Child Model, Disease Management, and Behavioral Health.
• Strong computer literacy and proficiency with relevant software and tools.
• Exceptional verbal and written communication skills.
• Familiarity with community resources and the ability to connect members with appropriate agencies.
• Bilingual in Spanish.

• A Master's degree in Social Work, Clinical Psychology, or Psychology is required. Specialization in Gerontology, Pediatrics, Public Health, Substance Abuse, Mental Health, or related fields is preferred.
• At least five (5) years of clinical work experience in the relevant field is required.
• An active, unrestricted Clinical Social Worker (LCSW) license may substitute for two years of work experience.
• An LMFT or LPCC with 3 years of clinical experience is also accepted.
• Experience in providing services and addressing psychosocial issues for one or more of the following groups is required: (1) adults, (2) children, or (3) young adults with disabilities and special needs. Experience in two or more groups is preferred.
• At least one (1) year of case management and care coordination experience is required.
• Experience in developing individualized, member-centered care plans is required.
• In-depth understanding of managed care issues, including benefits, contract limitations, delivery systems, reimbursement processes, and the role of medical management activities preferred.
• Familiarity with state and local social service agencies as well as community-based organizations preferred.
• Current certification in crisis prevention and intervention preferred.
• Expertise in community-based behavioral health care resources preferred.
• Knowledge of the distinct medical and psychosocial challenges faced by children and young adults with disabilities and special healthcare needs preferred.
• Bilingual in Spanish required.
• Certification in Case Management or a related field is preferred.
• At least one (1) year of experience in a clinical role within a managed care or health plan setting, including Medi-Cal or Medicaid, is preferred.

About Impresiv Health:
Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.

Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do – provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.

That’s Impresiv!