Medical Case Worker II - Wellness Team

SUMMARY

Housing for Health (HFH) is a program office within Health Services Administration, a division under the Los Angeles County Department of Health Services (DHS).

HFH was created and put into implementation in support of the Los Angeles County Homeless Initiative recommendations in response to and in support of the County’s effort to address and combat homelessness in the communities residing within Los Angeles County.

Our organization follows a hybrid work structure where employees work both remotely and from the office, as needed.

The Medical Case Worker, as part of the Client Wellness Team, will work under the supervision of the Senior Clinical Social Worker whose primary responsibility is to assess the needs, situations, strengths, and support networks of clients at the ERC facility.

The goal is to facilitate the transition of homeless individuals into permanent housing and provide comprehensive care within a 24-hour licensed care facility.

Furthermore, the Medical Case Worker will establish close collaboration with clients to facilitate the development and execution of personalized care plans, ensuring the fulfillment of their needs and the support of their goals.

The MCW will actively engage in conducting needs assessment and care planning, delivering supportive services, managing cases, maintaining documentation and reporting, advocating for clients, and performing other vital functions as outlined below.

ESSENTIAL FUNCTIONS

Under close direction of the professional staff, functions as a member of a multidisciplinary ERC clinical and program teams providing services to clients licensed care facilities to perform the following functions :

• Conduct comprehensive assessments of patients' medical, social, and psychological needs.
• Conduct face to face visits to clients in facilities to complete initial housing acuity index assessments and develop individualized care plans 90 days in collaboration with the patient, healthcare team, and other relevant parties.
• Provide weekly case management and coordinate services and supports according to the established care plan during the first 90 days of move into facility, including but not limited to the following :
• Provide bi-weekly case management services to clients who have been in the facility for 4-6 months.
• Utilizes environmental data gathered in relation to the medical or mental health problems to make recommendations concerning the provision of services that will ensure maximum benefits for each patient.
• Coordinate and monitor the implementation of the care plan, ensuring timely access to necessary medical services.
• Regularly evaluate and update the care plan based on the patient's progress and changing needs.
• Maintain accurate and up-to-date documentation of client assessments, care plans, interventions, and progress.
• Coordinate with insurance providers, public agencies, and community organizations to advocate for clients' access to necessary resources and services.
• Comply with legal and ethical guidelines regarding client confidentiality and information security.
• Advocate for clients’ rights and assist in resolving any barriers to accessing healthcare services.
• Educate clients about their living conditions and self-care techniques.
• Assist clients in understanding and adhering to prescribed medication regimens and healthcare recommendations.
• Offer information and referrals to relevant community resources and support services.
• Collaborate with healthcare professionals, social workers, and other stakeholders to ensure effective communication and coordination of care.
• Facilitate communication between the client, facility operator and the healthcare team, ensuring that all parties are well-informed and involved in decision-making.
• Attend interdisciplinary meetings and contribute insights regarding clients' medical and psychosocial needs.
• Prepare reports summarizing client' medical and social situations, highlighting any significant changes or concerns.
• Makes referrals to and works with various public and private health, mental health or other agencies such as the Department of Public Social Services, Legal Aid, Public Health Department, Free Clinics, to resolve client's personal and social problems.

JOB QUALIFICATIONS

Three years of experience in casework management, preferably in a healthcare setting in a medical case worker or case manager capacity, assisting patients / clients with social problems - OR - A Bachelor's degree from an accredited college or university and one year of professional casework experience interviewing, counseling, and assisting patients / clients with social problems.

Certificates / Licenses / Clearances

• A valid California Class C Driver License or the ability to utilize an alternative method of transportation when needed to carry out job-related essential functions.
• Successful clearing through the Live Scan and the Health Clearance process with the County of Los Angeles.

Other Skills, Knowledge, and Abilities

• Homeless health care experience.
• Experience with delivering clinical care services within ARFs and RCFEs.
• Familiarity with complex care management services for the care of high-need / high-cost Medical beneficiaries.
• Ability to lead teams in performance improvement activities.
• Demonstrated teaching and communication skills with non-clinical and clinical staff.
• Experience / expertise in assessing and managing clients with dysfunctional substance use disorder (SUD), including knowledge of MAT (Medication-Assisted Treatment) and Addiction Psychiatry.
• Experience / expertise in assessing and managing clients with serious persistent mental illness.
• Experience / expertise in trauma-informed care and harm reduction principles.
• Familiarity with DMH, DPH and community mental health and substance use programs and resources.
• Excellent communication and interpersonal skills, with the ability to establish rapport with diverse individuals and build effective relationships.
• Strong organizational and problem-solving abilities. Empathy, compassion, and a genuine desire to help others.
• Familiarity with relevant laws, regulations, and ethical standards in healthcare.
• Proficiency in using computer systems and healthcare software for documentation and data management.
• In-depth knowledge of medical terminology, healthcare systems, and available community resources.

PHYSICAL DEMANDS

Stand Frequently

Walk Frequently

Sit Frequently

Handling Occasionally

Reach Outward Occasionally

Reach Above Shoulder Occasionally

Climb, Crawl, Kneel, Bend Occasionally

Lift / Carry Occasionally - Up to 15 lbs.

Push / Pull Occasionally - Up to 15 lbs.

See Constantly

Taste / Smell Not Applicable

Not Applicable Not required for essential functions

Occasionally (0 - 2 hrs / day)

Frequently (2 - 5 hrs / day)

Constantly (5+ hrs / day)

WORK ENVIRONMENT

General Office Setting, Indoors Temperature Controlled

Heluna Health is an Affirmative Action,