The Social Worker, Senior field-based reports to the Manager, Social Services Management. In this role you will outreach to Blue Shield of California Promise Health Plan members and conduct assessments for social drivers of health needs and provide intensive interventions. The Social Worker, Senior field-based provides linkages to community resources to reduce social barriers, which enable members to receive and manage their medical care as well as remain living stable in the community. This position requires experience working with the Medi-Cal population and knowledge of community resources and related interventions.

Your Work

In this role, you will:

• Complete member assessments related to social drivers of health and access to healthcare needs in collaboration with a interdisciplinary case management team
• Collaborate with providers to support members' treatment plans and care needs
• Recognize members' right to self-determination as it relates to the ethical principle of autonomy, including the member/family's right to make informed choices that may not align with targeted outcomes as determined by the healthcare team
• Assess members' health behaviors, cultural influences and members' belief/value systems and evaluate all information related to current/proposed treatment plan and in accordance with clinical practice guidelines to identify potential barriers
• Efficiently manage and maintain a caseload of members with high severity and intensity of service needs such as members experiencing chronic homelessness, members experiencing severe and persistent mental illness or polysubstance abuse. Provide support to members, and/or members' support system, along with linkages to appropriate supportive services
• Coordinate services with state and community programs on behalf of the member, particularly when the member is unable to effectively do so independently
• Conduct field visits in settings such as but not limited to: hospitals, skilled nursing facilities, assisted living facilities, shelters, sober living homes, and private residences to complete assessments and provide psychosocial interventions. Engage with members, and/or members' support system, in planning safe discharges and transitions between settings
• Document psychosocial assessment and referrals thoroughly and in a timely manner according to established standards and guidelines
• Actively participate in Interdisciplinary Team Meetings and case consultations