Cal AIM Rapid Response Care Manager II

IOA is on the forefront of revolutionary healthcare models, reshaping the way people can age in place. Our innovative models transform lives, enhance communities, and save healthcare systems millions of dollars. Rather than focusing on archaic outdated design, we strive to consistently question the "status-quo" and create new and more innovative ways to help aging adults and adults with disabilities maintain their quality of life. With over 23 programs, we offer multiple ways to aid seniors maintain their health, well-being, independence and participation in the community, fulfilling our mission.

RESPONSIBILITIES

• Meets with clients and potential clients to provide same-day services, responding to referrals within 24hrs or as indicated by supervisor.
• Conducts in person visits at hospitals, skilled nursing facilities and other settings to complete screenings and psychosocial assessments for Cal AIM services
• Establishes, develops and maintains excellent working relationships with emergency department/hospital teams, health plans and other relevant community services
• Completes a weekly rotation system at different hospitals to support ED referrals, enrollments and intakes
• In a timely manner, gathers relevant information and writes comprehensive assessments and community living plans that are client-centered and consistent with program guidelines and policies and procedures.
• Travels across counties to support ED and community enrollments
• Coordinates with hospital team to follow up on tasks identified in discharge planning and to ensure linkage to services
• On a monthly basis, prepares a report with client referral data, documentation completion and outcomes and submits to supervisor
• Attends MDTs and other meetings as determined by supervisor to coordinate services with hospital team and health plan on pending and upcoming referrals
• Submits all the documentation on a timely manner. Maintains required paperwork and follows a clear, concise, and consistent system of charting to allow for continuity of care.
• Participates in community outreach presentations and events on a regular basis
• Engages potential clients and family members in services to complete intake and assessment/community living plan
• Checks Point Click care on a daily basis to manage clients or pending referrals who have been admitted to hospital
• Identifies, arranges for, and monitors appropriate community services based on a good knowledge of Medicare, Medi-Cal, and other entitlement programs.
• Establishes and maintains a care management relationship with clients and their informal support network as appropriate, offering respect, dignity and support. Provides crisis intervention, advocacy, problem solving and therapeutic interventions.
• Documents via progress notes all case management activity regarding identified problems within 24-48 hours, adding any new problems to the Community Living Plan, as needed.
• Ongoing evaluation for client Purchase of Service needs and follow-up to determine if services have been provided in a timely manner.
• Educates clients and informal support network about resources.
• Establishes and maintains open and effective communication with community providers, including physicians and other health care and social service workers. Provides appropriate information on all significant aspects of individual client care and program operations, while maintaining necessary confidentiality.
• Monitors the quantity and quality of the services provided by other involved providers.
• Working closely with the team, continuously evaluates the clients' ability to remain safely at home; coordinates placement as appropriate, according to program guidelines.
• In collaboration with the client, caregiver, and involved services, terminates clients when appropriate. Documents the process as required.
• Participates in and promotes ongoing efforts towards Continuous Quality Improvement.
• Attends and actively participates in team and program meetings, trainings, activities and problem-solving endeavors; contributes to open lines of communication within the team.
• Utilizes supervision appropriately; maintaining open lines of communication and providing updates on caseload activity.
• Actively incorporates the ethical and legal standards of the National Association of Social Workers into all aspects of interactions with others.
• Understands and applies the regulatory and procedural requirements of the Institute on Aging.
• Attends continuing education classes and/or in-service training to increase knowledge, skills and attitudes related to case management, gerontology, family and community systems and other areas relevant to the client population.
• Complies with mandated report requirements as stipulated by state guidelines (e.g APS reports)
• All other reasonably related responsibilities as assigned.

EDUCATION:

• M.S.W. (Masters in Social Work) or related degree required; LCSW preferred
• In lieu of a Masters degree, an employee may qualify for a Care Manager II position with a BA or BS in Social Work or another appropriate major and a minimum of two (2) years of relevant social work experience and the ability to demonstrate autonomous work in conceptualizing and formulating biopsychosocial assessments, identifying care needs and necessary interventions, and then executing effective care interventions

QUALIFICATIONS

• At least one year working with disabled adults and/or older adults required.
• Flexibility to adapt and respond effectively to a fast-paced work environment
• Ability to maintain composure and focus under pressure, managing deadlines and competing demands effectively.
• Maintaining a positive outlook when facing unexpected challenges or adjustments in priorities
• Ability to work in the field several days a week
• Excellent time management and documentation skills
• Collaboration skills and ability to work effectively in or across several teams
• Knowledge of transitions of care
• Experience with and understanding the medical and psychosocial problems of functionally impaired adults and older adults.
• Experience working with individuals with mental and/or behavioral health diagnoses and substance abuse disorders highly desired.
• Exceptional communication and presentation skills relating to functionally impaired adults and older adults, their support systems and teams of health professionals.
• Demonstrates case management skills and experience in the community health care delivery system.
• Skills in client and family advocacy
• Detail oriented with good problem-solving skills and the ability to prioritize multiple tasks.
• Computer literacy required.
• Language

COMPENSATION:

Range: $84,077 - $100,485/Annual

This amount is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any specific employee, which is always dependent on actual experience, education and other factors.

We encourage you to learn more about IOA by visiting us here.

IOA reserves the right to adjust work hours or duties when appropriate.

Institute on Aging is an Equal Opportunity Employer. Institute on Aging is committed to cultivating a diverse and inclusive work environment and providing equal opportunities to all employees and job applicants without regard to age, race, religion, color, national origin, sex, sexual orientation, gender identity, genetic disposition, neuro-diversity, disability, veteran status or any other protected category under federal, state and local law.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.