Social Worker; Home visits in Fresno Job Fresno area,California USA,Healthcare

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail.

It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them.

Together.

Alignment Health is seeking a social worker to join the Care Anywhere team to conduct home / SNF visits in Fresno (4 home visits per day with mileage reimbursement) and telehealth visits for Madera and Merced. The Social Worker assess’ and evaluates members’ needs and requirements to achieve and/or maintain their health. Guides members and their families toward and facilitate interaction with resources appropriate for their care and well-being.

Works in collaboration with a multi-disciplinary teams, employing a variety of strategies, approaches and techniques to enable a member to manage their physical, environmental and psycho-social health issues.

Schedule

Monday - Friday, 8:00 AM - 5:00 PM

GENERAL DUTIES / RESPONSIBILITIES

Conducts telephonic outreach to assigned members to assess health, environment, nutrition, and psycho-social areas of concerns using a variety of assessments.

a. In response to assessments, coaches and problem solves with member to identify and address specific goal(s) to support health and behavior change.
b. Provides appropriate interventions to optimize health and well-being. Interventions may include education, the coordination of community-based support services, and other resources.
c. Charts member's treatments and progress in accordance with state regulations and department procedures.
d. Makes referrals to case manager, as appropriate, and/or refers member's family to community support services and resources.

Provides home assessment to high-risk members and develop an individual care plan

Collaborates with physicians in screening and evaluating members for psychotropic medications.

To better serve members and implement the model of care, understands the clinical program design, program monitoring and reporting.

Practices as an interdependent member of the health team and provides important components of primary health care through direct social work services, consultation, collaboration, referral, teaching, and advocacy.

Assesses and treats outpatients in individual and family modalities exercising mature professional judgment and using a wide range of social work skills to include individual and family counseling to assist patients and their families in dealing with chronic and acute diseases/injuries.

Conducts psychosocial assessments to determine patient needs and resources (both family support and community support). Provides counseling to patient and family in matters directly related to patients’ limitation, adjustment to medical condition, and ongoing treatment. Develops and implements discharge plans, follow-up care, and transfers to other health care facilities (e.g., nursing homes, rehabilitation hospitals, etc.)

Provides consultation services to medical, nursing, and ancillary hospital staff regarding psychosocial issues, discharge plans, and follow-up care for patients and families.

Provides crisis intervention services.

Responds independently, and with various media, to appropriate community requests. Take the initiative in seeking out opportunities to present programs to meet the needs of patients/members and their…