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 Rather than focusing on archaic outdated design, we strive to consistently question the “status-quo” and create new and more innovative ways to help aging adults and adults with disabilities maintain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. Responsible for the assessment of clients with multiple medical and psychosocial needs. Plans for and monitors services and interventions ensuring provision of quality care. Responsibilities include meeting with clients and potential clients to provide same-day services, responding to referrals within 24hrs or as indicated by supervisor; conducting in person visits at hospitals, skilled nursing facilities and other settings to complete screenings and psychosocial assessments for Cal AIM services; offering services on site at different hospitals as assigned; establishing and maintaining excellent working relationships with emergency department/hospital teams, health plans and other community services; completing weekly rotation at different hospitals to support ED referrals, enrollments and intakes; gathering information and writing comprehensive assessments and community living plans; traveling across counties to support ED and community enrollments; coordinating with hospital teams for discharge planning and linkage to services; preparing monthly reports; attending MDTs and other meetings; submitting documentation timely; participating in community outreach; engaging clients and families; managing clients or referrals admitted to hospital; identifying and monitoring community services; establishing care management relationships; providing crisis intervention, advocacy, problem solving and therapeutic interventions; documenting case management activity; evaluating client Purchase of Service needs; educating clients and support networks; maintaining communication with community providers; monitoring service quality; evaluating clients' ability to remain safely at home; terminating clients when appropriate; participating in Continuous Quality Improvement; attending team meetings and trainings; utilizing supervision; incorporating ethical and legal standards of the National Association of Social Workers; understanding and applying regulatory requirements of the Institute on Aging; attending continuing education; complying with mandated report requirements; and other related responsibilities. Education required is M.S.W. or related degree preferred LCSW. In lieu of Masters, BA or BS in Social Work or related major with 2 years relevant experience may qualify. Qualifications include at least one year working with disabled or older adults, flexibility, composure under pressure, ability to work in the field several days a week, excellent time management and documentation skills, collaboration skills, knowledge of transitions of care, experience with medical and psychosocial problems of impaired adults, experience with mental/behavioral health and substance abuse desired, communication and presentation skills, case management skills, client and family advocacy, detail orientation, problem-solving, and computer literacy.