- Conducts and writes comprehensive assessments and on-going re-assessments of assigned clients, including psychosocial, physical and mental health, environmental, and spiritual needs.
- Creates and initiates a client-centered care plan, provides counseling, monitoring and care plan changes as necessary as outlined in the Case Management Accredited Policy and Procedure Manual.
- Identifies, arranges for, and monitors appropriate community connections and services, based on knowledge of Medicare, Medi-Cal and other entitlement programs.
- Establishes and maintains a professional care management relationship with clients and significant others with respect, dignity and support.
- Provides crisis intervention, advocacy, and problem solving and therapeutic interventions.
- Meets with clients at least quarterly or more as needed.
- Calls clients monthly for follow-up and check ins.
- Reviews and modifies client Care Plan on an ongoing basis.
- Progress notes inclusion of care activity and discussion with client; referring to the identified goal in the care plan is completed within 24-48 hours, adding new goals to the service plan as needed.
- Maintains required paperwork and follows a clear, concise and consistent system of charting to allow for continuity of care.
- Educates clients and significant others about resources and, when possible, trains them to advocate for themselves in time of need.
- Establishes and manages 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 the individual client care and program operations while maintaining confidentiality.
- Collaborates with the team, continuously evaluating clients’ ability to remain living safely at home or coordinating placement options as appropriate.
- In collaboration with the client, caregiver and involved services, discharges clients from services when appropriate and documents the process as required.
- Maintains accurate, current, and complete client files and completes all required data collection forms and reports. Maintains appropriate records for monthly reports.
- Data entry into CA GetCare, and Catholic Charities -CARES Data Systems and completion of monthly reports.
- Participates in staff meetings, client peer reviews, in services and other trainings as required.
- Participates in research studies and promotes ongoing efforts towards Continuous Quality Improvement.
- Actively participates in team and program meetings, 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.
- Implements the ethical standards of the National Association of Social Workers in all aspects of interactions with others.
- Implements regulatory and procedural requirements of Catholic Charities policies and procedures.
- Attends continuing education classes and/or in-service training to increase knowledge, skills and attitudes related to case management, gerontology, family, community systems and other areas relevant.
- Nothing in this job description restricts management's right to assign or reassign duties and responsibilities to this job at any time.
- Master’s Degree in Social Work, Psychology, and Counseling or another related field and at least one year of relevant experience related to the job description.
- Minimum two years of experience providing client case management services with the aging population and/or service programs.
- Exceptional communication and presentation skills relating to the frail elderly, functionally impaired adults, their support systems and teams of health professionals.
- Demonstrates case management skills and experience in the community health care delivery system.
- Detail oriented with good problem-solving skills and the ability to prioritize multiple tasks.
- Knowledge of community resources.
- Desire to work with and sensitivity to the aging population and diverse cultures.
- Bi-lingual in Mandarin/Cantonese, Tagalog, Spanish, or other language capacity (Highly Desirable).
- Computer literacy (Required).
- Ability to perform duties with minimal supervision.
- Ability to communicate clearly in both verbal and written forms.
- Desire to promote a positive, professional and organizational image in the community.
- Sensitivity to seniors and their needs.
- Sensitivity in handling complex/confidential information.
- Ability to work under pressure.
- Ability to work as a member of a team.
- Although preferred, driving is not required.
- Certified in Red Cross, First Aid and CPR required. Ability to be obtained within 30 days of hire.
- Demonstrates the necessary attitudes, knowledge and skills to deliver culturally competent services and work effectively in cross-cultural situations.
- Is responsible for accurate and timely data entry that aids Performance and Quality Improvement (PQI) reporting and case record reviews.
- Is responsible for accurate and timely submission of case records.
- Serves on a quarterly case record review committee for Performance and Quality Improvement (PQI) reporting.
- Serves on department or program Performance and Quality Improvement PQI Committee responsible for monitoring goals and reporting.
- Frequent bending, standing, stooping, kneeling, reaching, twisting, and walking.
- Intermittent lifting, pushing, and pulling.
- Frequent repetitive motions: Making substantial movements (motions) of the wrists, hands, and/or fingers.
- Light work: Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects.
- The worker is required to have close visual acuity to perform an activity such as: preparing and analyzing data and figures; transcribing; viewing a computer terminal; and extensive reading.
- Driving is required for this position.
- May include contact with clients with mental health issues who demonstrate behaviors such as use of profanity, shouting, running away, self harm and violence.
- The worker is occasionally exposed to cleaning products.
- The worker is occasionally exposed to perfume or scents in personal care products used by employees, clients, and visitors.
- The worker is regularly exposed to arts and crafts supplies that may contain an odor such as non-toxic paint, glue, permanent markers, dry erase markers and crayons.
- The worker is occasionally exposed to latex, bleach solution, cigarette smoke, and animals for pet therapy projects.
- The worker is subject to atmospheric conditions: One or more of the following conditions that affect the respiratory system of the skin: Fumes, odors, dusts, mists, gases or poor ventilation.
- The worker is subject to noise: Noise level in work environment can be moderate to excessive.
- The worker is subject to outside environmental conditions: No effective protection from weather.
- The work environment includes traveling using various modes of transportation.
Professional Field
Counseling
Social Work
Other Behavioral, Mental, or Healthcare FieldPatient Focus
Diagnoses
Avoidant Personality Disorder
Gender Dysphoria
Issues
Aging
Age Groups
Adults
Therapeutic Approach
Methodologies
ECT
Modalities
Families
Individuals
Practice Specifics
Populations
HIV/AIDS
Inmates
Victims of Crime/Abuse (VOC/VOA)
Aviation/Transportation
Racial Justice Allied
Settings
Faith-based organizations
In-patient Non-Psychiatric
In-patient Psychiatric
Milieu
Research Facilities/Labs/Clinical Trials
Schools
Home Health/In-home
Military
Forensic





