SUMMARY
Reporting to the Program Lead, the Social Worker/Clinical Therapist (Pre-Licensed) is responsible for working effectively with, and as part of the Community- Based Care Management Entity (CB-CME) to provide high quality, effective care management to Population Health Program in either the Enhanced Care Management (ECM) or My Path members. Responsibilities include outreach and engagement to members, engaging members in skilled therapeutic interactions to promote healthy behaviors, other behavioral health interventions within scope. This includes coordination of care, resource linkages; collaborating 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 and coordinates with the Primary Care Practice (PCP).

DUTIES & RESPONSIBILITIES

· Responsible for primarily working with a caseload of Members with behavioral health needs (may be Tier 1 or 2).

· Conducts monthly eligibility verification of assigned patients.

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

· Responsible for brief crisis interventions and warm hand-offs to local crisis resources as needed to address behavioral health needs and assists with connections to telepsychiatry.

· Responsible for communication with In-house psychiatrist and linkage to Behavioral Health resources.

· Provide Member and family education about chronic medical and behavioral health conditions to improve health literacy.

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

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

· Track medical and behavioral health outcome measures in a patient record and/or data bases.

· Ensure smooth transitions of care and coordination with psychiatric hospitals regarding client admission/ discharges.

· Collaborate on Member care issues with other CB-CME team, participating in weekly systematic case reviews and ad hoc case reviews.

· Work with Members to identify health/wellness goals and incorporates these goals into the Member’s Health Action Plan/Shared Care Plan that facilitates communication among Members and Providers.

· Responsible for ongoing engagement with Members, both in-person and on virtually, 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.

· Provide consultation for all members of the team when discussing tasks within LCSW’s scope of practice and responsibility.

· Other duties as assigned.

MINIMUM QUALIFICATIONS

Education/Certification

· Master’s degree related field

· Experience in Case Management and Behavioral Health

· Valid California driver’s license.

· Reliable means of transportation.

SKILLS/EXPERIENCE

· Minimum of (1) one year of experience performing or facilitating Behavioral Health services in a health clinic/psychiatric hospital, medical facility, or health care clinic.

· Experience in Case Management

· Demonstrated experience working within a team, and experience in developing and maintaining effective relationships with both clients and team members.

· Demonstrated experience and skill in conducting motivational interviews and/or other evidenced based communication and therapeutic strategies.

PREFERED QUALIFICATIONS

· Experience in clinical services, mental health and/or substance use.

· Bilingual (preferred)