Job Title: Clinical Social Worker, LCSW
Location: Cedars-Sinai (Beverly Hills, CA)
Job Description
This position is responsible for the development, planning, implementation, and evaluation of all social service related interventions for the Case Management Department. Specifically, this position will be responsible for indentifying patients who have psycho/social needs on an inpatient or outpatient basis. The social worker is responsible for developing patient care goals and treatment plans as agreed upon by the patient’s primary care provider. The Ambulatory Case Manager/Social Worker is also available to physicians and nurse case managers as a consultant for those patients with complex psychosocial needs.
ESSENTIAL JOB DUTIES:
• Evaluate and implement with the assistance of the Clinical Social Work Supervisor
and Manager of Outpatient Case Management, a high touch ambulatory case management
intervention for patients with psycho/social issues. With particular focus on seniors,
catastrophic and chronic patients. Specifically:
• Development: Depression Screening tools for selected populations; IS reports for outcome
measurement
• Implementation: triage patients with the ambulatory case management team; assist in
coordination of patient care delivery, including DPA; document pertinent information in the
case management tools and communicate to team.
• Evaluation: evaluate caseload daily and assess achievement of long and short term goals;
modify goals with providers and case management based upon patient outcomes; compile
and present statistics and reports relating to patient outcomes; document findings in the
patients EHR
• Communication: provide follow up and outcome communication to the referral source, IE,
PCP, family member, case manager, home health personnel, community social worker,
Health Plan, ect.
• Participate in the weekly virtual care team meetings
• Act as social services liaison for the department and physician offices, particularly in the
areas of:
• Complex discharge planning
• Referral to agencies which provide supportive services to fragile patients
• Assist in arrangement of community resources (i.e. meals on wheels, transportation
services, adult day care, and info-line)
• Assist in long term planning for patients transitioning to an institutionalized setting
• Provide alternatives for patients requiring specific services while lacking insurance coverage
• Act as liaison to Population Health department in regard to chronic disease state
management programs
• Facilitate as liaison to the Member Services and QI departments to address any ongoing
case management issues or concerns identified via the "Voice of the Customer" Program.
• Assist in the development and implementation of new policies and procedures for the
department as they relate to high-risk patient populations.
• Develop and maintain resource directory for physicians and case management staff.
• Participate in advanced care planning initiatives
• Performs other duties as assigned.
