Summary:

Under the general supervision of the Licensed Clinical Social Worker and the Health Homes Program Operations Manager, the Associate Clinical Social Worker (ACSW) is responsible for working effectively with the Health Homes Program members and Care Teams. The ACSW functions as a proactive team member in the integration of Behavioral Health services into the Primary Care setting. The ACSW will provide Care Management Services including but not limited to: outreach and engagement to members, engaging members in skilled therapeutic interactions to promote health behaviors, other behavioral health interventions within scope, coordination of care, resource linkages, working with other professionals and organizations in the community to ensure quality of care for members, seamless transitions of care, and facilitating the right care and the right time for the member. Is responsible to be a liaison between the Patient, Primary Care Providers and Behavioral Health Providers. Is responsible for caseload management Assists in the integration of whole-person care with goals towards meaningful data collection and improving the health and well-being of the targeted population. Demonstrates willingness to assist co-workers whenever needed. Maintains good working relationship with all clinic personnel. Provides compassionate quality care to the patients of Borrego Health.

Essential Duties and Responsibilities:

1. Caseload Management: Responsible for primarily working with a caseload of HHP Members with behavioral health needs.

2. Responsible for utilizing brief behavioral health therapeutic interventions as necessary to improve the Member’s ability to manage their own health.

3. Provide formal and informal training and support for HHP Members on behavioral health conditions, including treatments and evidence-base for treatment.

4. Responsible for assisting Members with care coordination needs, including, but not limited to, the following:

5. Ensuring completion of the Complex Health Assessment (CHA) for all eligible HHP high-risk Members.

6. Assimilate CHA information into an Shared Care Plan (SCP)/Health Action Plan (HAP)

7. Communicate SCP with Member, approved family or caregiver and other Members of the care team.

8. Participate in multi-disciplinary care team meetings to share information, update and inform care plan.

9. Coordinate with internal and external health partners to support Member’s comprehensive care needs

10. Participate and lead (as necessary) for care transition plan responsibilities.

11. Provide active, on-site support for Members and care team staff

12. Assists patients to follow through in their care plan/wellness goals using both phone and in-person contact.

13. Model the highest ethical behavior in relationships with co-workers, supervisors, Members, Providers, and colleagues in the community.

14. Responsible for promoting a collaborative and effective working environment within the organization by engaging in evidenced-based communication strategies (such as Motivational Interviewing) when discussing responsibility/sharing of tasks, effectively resolving conflicts as they arise, and collaborating on Member case discussions.

15. Provide formal and informal training and support for HHP members on behavioral health conditions, including treatments and evidence-base for treatment.

16. In conjunction with the LCSW and/or HHP Operations Manager, the Behavioral Health Care Manager is responsible for providing consultation for the non-licensed members of the team when discussing tasks of a clinical nature.

17. Responsible for building and maintaining a positive working relationship with Providers, including, but not limited to, communication via in-person, over the phone, and through digital means such as email and fax.

18. Responsible for engaging with Members, both in-person and on the phone, in a manner that utilizes evidence-based approaches (such as Motivational Interviewing) that promotes collaboration between the Member and his or her medical/behavioral team, as well as to increase the Member’s sense of control over their whole health.

19. Model commitment to continuous quality improvement by engaging in quality improvement initiatives and projects, such as by identifying and addressing gaps, and by identifying, developing, and testing new practices for improving the outcomes of the HHP.

20. Assists with the coordination of medical and behavioral health access issues with PCP offices, specialists, and ancillary services.

21. Collaborates on Member care issues with other teams, participating in weekly systematic case reviews and ad hoc case reviews, and consults with Nurse Care Manager, Licensed Clinical Social Worker and/or the Behavioral Health Clinician before taking any action that is clinical in nature.

22. Ensures documentation is accurate and in compliance with regulatory requirements and accreditation standards.

23. Participates in staff meetings, trainings, committee meetings, or other activities as needed or as directed by Leadership Team Members.

24. Maintains up-to-date documentation and non-billable notes on patients.

25. Other duties as assigned.

Qualifications:

Minimum Qualifications:

1. Required: Associate Clinical Social Worker (ACSW)

2. Experience: Previous experience in the medical field and /or, in the Behavioral Health / Mental Health field is preferred.

3. An understanding of, or ability to learn, Behavioral Health as associated with Chronic Medical Diseases.

4. An understanding of, or ability to learn, Biological and Physiological nature of Mental Illness Diseases.

5. An understanding of, or ability to learn, Insurance and basic Medical terminology

6. All staff that is presently working within a clinic is required to have a Current and Valid CPR and First Aide certification on file with the Human Resources Department. This is for clinical and administrative staff. This new license requirement is mandatory for continued employment, CPR and First Aide certification must be obtained through the American Heart Association. Internet certificates do not comply and for this reason are not valid.