Location: 8700 Beverly Blvd, West Hollywood, CA 90048 Required: * MSW * 2+ years of Case Management experience * Experience with adult/child protective services Preferred: * LCSW with CA license * Hospice and Acute Care experience * Epic experience Primary Duties and Responsibilities • Evaluates and implements social service programs for patients with psycho/social issues focusing on seniors, catastrophic and chronically ill patients. • Develops social service documentation tool/templates in EMR for Social Work consults, family counseling and group sessions and IS reports for outcome measurements. • Performs triage for patients within corresponding team(s) and assists in coordinating patient care delivery, including DPA/POSLT and documents pertinent information in the case management system. • Implements transitions of care between inpatient and continued outpatient follow up and vice versa. • Initiates team care conference to include patient, family and care providers. • Evaluates daily caseload and assess achievement of long and short term goals; Modifies goals with providers and care team based upon patient outcomes. • Compiles and presents statistics and reports relating to patient outcomes and document findings in the patients EMR. • Follows up on communication to the referral source, IE, PCP, family member, case manager, home health personnel, community social worker, Health Plan, etc. • Acts as the social services liaison for the department, particularly in the areas of: Advance Care Planning discussions, Complex discharge planning, Biopsychosocial assessments. • Refers patients to agencies that provides supportive services optimizing patients health plan benefits. • Assists in arranging community resources (i.e. meals on wheels, transportation services, adult day care, and info-line) and in the long term planning for patients transitioning to institutional setting. • Provides alternatives for patients requiring specific services. • Acts as the liaison to Population Health department in regard to chronic disease state management programs. • Assists in the development and implementation of new policies and procedures for the department. • Participates in advance care planning initiatives.