As part of the program and in support of its aims, this position provides professional clinical social work services to patients and families presenting difficult medical and related psychosocial problems in various clinical settings (primarily clinics and community ambulatory health care) to assist them in resolving their social and structural challenges to health and in making effective use of the healthcare system and community services. Also, performs professional social work services in connection with and coordination of the treatment of clients in need of psychosocial, mental health, and economic stability services, especially to prevent and address the risk and consequences of childhood adversity.
Essential Job Functions:
Delivers longitudinal social risk/need resource coordination services - including but not limited to Medical-Financial Partnership clinical, treatment, and support activities - in the prenatal, family medicine, and/or pediatric clinic setting.
Supports connection to psychosocial, mental health, and economic stability supports from prenatal, perinatal/nursery, pediatrics, and/or family medicine care as well as community supports.
Supports and supervises Medical-Financial Partnership team members, including but not limited to MSW trainees.
Collaborates and coordinates with health care team members, including but not limited to: health care team trainees, e.g., medical students, residents, nurse practitioner students, etc.; LAC-DHS social workers, and community service providers to respond to adverse childhood experience exposures and psychosocial, mental health, and economic risk/need identified through clinical workflows.
Provides direct Medical-Financial Partnership family resilience coaching services to patients and caregivers in the prenatal, pediatric, and/or family medicine clinical settings.
Conducts interviews, assessments, and evaluations ofpatients and family members to identify social, emotional, and economic barriers, needs, and strengths and identify factors which may interfere with obtaining maximum benefits from medical care and community services that support prevention of childhood adversity, trauma, and social risk.
Identifies, makes referrals to, coordinates, and monitors community resources/agencies, other professional disciplines, and County departments to provide services in accordance with the patient treatment plan.
Documents the social/emotional assessments, progress, and treatment plans made and the treatment rendered in accordance with utilization review standards issued by healthcare regulatory agencies. This includes documentation in the medical record with communication to members of the primary care team.
Develops and implements a social work treatment plan in consultation with Medical-Financial Partnership team in coordination with the clinical social work team, when appropriate, and in collaboration with patients and family members based upon an analysis of the patient and families’ psychosocial and economic factors, including barriers, strengths, and needs.
Participates in multi-disciplinary health team conferences to formulate, assess, and consult about the overall patient/family care plans by interpreting to the team the psychosocial and economic aspects of the patient and families’ circumstances.
Participates in multi-disciplinary orientation sessions and in-service training for other disciplines through lectures and group discussions to heighten awareness and increase understanding of the psychosocial risks and needs associated with a particular illness.
Attends in-service training programs, continuing professional education, seminars and workshops to support ongoing continuing education and workforce development in accordance with California state licensure requirements (if applicable) and to continue professional development in social work practice, mental health theory, and in the effective delivery of healthcare services.
Manages coordination and monitoring of daily calendar, team meetings, and visits for all Medical-Financial Partnership team members and all Medical-Financial Partnership clinical encounters.
Facilitates daily team huddles and additional team meetings, manages the Medical-Financial Partnership calendar, and supervises team’s daily care coordination and service responsibilities. This includes but may not be limited to supervising and providing performance feedback and support to Medical-Financial Partnership staff reporting to the Coordinator, ensuring fidelity of the Medical-Financial Partnership services delivered, supporting service delivery through quality improvement and quality assurance activities, and participating in evaluation of program implementation, staff training, and impact.
Confers with program directors, program managers, and others they report to concerning human resources, program resources and structures, work problems and opportunities for increased program effectiveness.
Implements clinical workflows for family strengths and needs identification and response in collaboration with Medical-Financial Partnership supervisors, program directors, team, and providers across all clinical settings by determining type and level of Medical-Financial Partnership and other services to be provided; doing quality-assurance; and carrying out policies and procedures.
DESIRABLE QUALIFICATIONS:
At least 2 years Post-degree experience working in a multidisciplinary team within a medical setting assessing psychosocial needs of patients and families
At least 2 years Post-degree experience evaluating infant, family, early childhood mental health and developing interventions/care plans
Able to work in a fast-paced environment with minimum supervision
Spanish language fluency
Previous experience supervising and/or managing individuals or teams, ideally MSWs or MSW interns/students
MINIMUM REQUIREMENTS:
OPTION I - A Master's Degree* in Social Work from a graduate school accredited by the Council on Social Work Education including supervised clinical social work field work experience. - OR -
OPTION II - A Master's Degree in Social Work from a graduate school accredited by Council on Social Work Education and one year of experience in medical, mental health, child- and family-facing services, or child welfare social work setting(s) involving problems of medical, mental, or emotional adjustment in a medical setting.
