Social Worker,MSW Job Los Angeles area,California USA,Social Work

Essential Functions and Work Responsibilities Functional Category:
Assessment & Care Planning

Conducts initial psychosocial assessments (including SLUMS, PHQ-9, housing, food, financial security, MDPOA/decision-maker status).
Completes in-person reassessments at least every six months or as required.
Performs in-home visits as required by regulations or as indicated
Participates in IDT meetings, morning huddles, mini-teams, and PDPM meetings to ensure coordinated care.
Facilitates and documents participant care conferences, family meetings, and facility partnership meetings.
Participates in discharge planning and plan of care development, ensuring problems, interventions, and goals are well defined.
Supports participants transitioning between residences or care facilities, including arranging transportation and coordinating moves when no support system is available.

Functional Category:
Case Management & Care Coordination

Serves as primary liaison between participant/family and the IDT, facilitating communication and resolution of care issues.
Coordinates respite SNF, ALF admissions, including transportation and discharge planning.
Documents housing encounters in EPIC
Collaborate with comfort care team for end-of-life activities
Assists participant’s family with end-of-life coordination
Collaborates with RN Case Management on hospitalizations, and provides psychosocial input
May serve as back-up to RNCM.
Reviews participant/family concerns with Ombudsman and escalates facility quality concerns; maintains admission holds on facilities with care issues and manages urgent rehousing when contracts terminate.
Coordinates guardianship process for participants lacking decision-making capacity without a surrogate.
Obtains SNF/ALF updates for IDT, manages respite scheduling, and ensures placement transitions are supported.
Provides options counseling when appropriate
Assists participants who are disenrolling with timely referrals to external services and completion of disenrollment paperwork.

Functional Category:
Psychosocial Support & Advocacy

Provides counseling and psychosocial support in coordination with behavioral health for participants and caregivers as indicated
Completes comfort care assessments and provides guidance on transitions to end-of-life services.
Advocates for participants living in unsafe housing conditions
Contributed to RCAs development, incident reporting, and follow-up for abuse, neglect, exploitation, and elopements.
Assists participants and caregivers with grievances and appeals, explaining rights and processes.
Provides notification and explanation of participant rights regarding Level of Care (LOC) denials or disenrollment declines.

Functional Category:
Documentation & Compliance

Maintains accurate and timely documentation in Epic, Eirene Rx, and other systems (demographic updates, address/phone changes, participant chart updates).
Complete PASSR screenings, supportive housing forms and other like documents as mandated by federal and state agencies within regulatory timelines.
Supports Medicaid eligibility recertification processes,
Partners with Eligibility Financial Determination teams to educate participants/families on required information/documentation needed to maintain and restore Medicaid eligibility
dictation, and assists with resource compliance.
Accurate and timely reporting of disenrollments in required systems
Escalates to Center Director service recovery is needed for a participant concern or disenrollment
Ensures all participant care coordination complies with CMS, HCPF, and Innov Age policy requirements.

Functional Category:
Professional Development & Team Collaboration

Participates in IDT and department meetings, cross-site collaboratives, trainings, and annual competencies.
Provides…

Social Worker, MSW