Job Summary

The Social Worker III provides services within the Social Services Department under the CALAIM Community Supports Recuperative Care Program. This position is key in the adjudication and monitoring of referrals into the Recuperative Care Community Supports program. This position ensures that members meet criteria and achieve program goals during their Recuperative Care stay in accordance to California Department of Health Care Services (DHCS) guidelines and with the organization's mission, values, and strategic goals.

In addition, the Social Worker III is responsible for working in collaboration with all Recuperative Care providers and healthcare team members to implement interventions that support patient-centered care for both patients and the medical community. This position provides training on the delivery of CALAIM Recuperative Care Services and maintains professional relationships with hospital staff (including physicians, case managers, nursing staff), Participating Physician Group (PPGs), county agencies, and other health care providers and provides technical support and clinical consultation.. This position engages with various stakeholders, community partners, and Community Based Organizations (CBOs) in a manner that promotes collaborative working relationships.

The Social Worker III is required to attend high level meetings addressing hospital complex cases, as well as participate in committees addressing complex needs of mental health and medical needs of patients.

Duties

Performs the adjudication and review of L.A. Care’s Recuperative Care Prior Authorization Request and clinical documentation using the “Community Supports: Recuperative Care Criteria” and in accordance to DHCS timelines.

Creates authorizations and or denials based on criteria and exclusion criteria. Manages referral placement and makes clinical decisions to place the member in the Recuperative Care setting that best meets their needs.

Communicates with referrer to assure transitions of care services are arranged prior to discharge, this includes home health, Durable Medical Equipment (DME), Primary Care Physician (PCP) and specialist follow up care in order to avoid delays. Provides technical assistance that minimize challenges that may delay the member's transition.

Conducts care conference meetings with each recuperative care provider to ensure members’ goals are on track and being met. Monitors referrals during their recuperative care stay and provides support in the discharge planning process. Utilizes data gathering in relation to the medical or mental health problems to make recommendations concerning the provision of services that will ensure maximum benefits for each patient. Reviews bed transfer and bed extension request. Approves or denies requests based on the programs criteria.

Supports internal and external stakeholders, particularly hospital staff by advocating and connecting member resources, to Community Supports programs, Enhanced Care Management (ECM), Behavioral Health, Managed Long Term Services and Supports (MLTSS) and governmental aide programs such as Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), Veteran Benefits.

Participates in meetings and committees addressing needs of high utilizers and hospital complex cases. Provider creative and attainable solutions.

Performs other duties as assigned.

Duties Continued

Education Required

Education Preferred

Experience

Required:
Minimum of 2 years of medical social work experience.

Must have at least 2 years of inpatient acute medical hospital experience.

Knowledge of managed care, previous experience with a health plan, and an understanding of Medi-Cal and Medicare programs.

Skills

Required:
Must be highly motivated and a self-starter.

Ability to communicate with and relate to a diverse group of people including clients, community, and other staff.

Must have excellent administrative and organizational skills.

Strong customer services and excellent verbal and written communication skills.

Strong analytical, conflict resolutions and persuasion skills.

Proficiency with Microsoft Office including Outlook, Word, and Excel.

Ability to exercise clinical and independent judgment.

Preferred:
"Bilingual in one of LA Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese ".

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information

This position may require weekend and after-hours assignments in order to meet regulatory decision deadlines.