POSITION SUMMARY :The Social Worker provides direct case management services to patients, focusing on helping patients and their families / caregivers cope with social, emotional, and practical issues related to maintaining their independence. Reporting to the Regional Social Work Manager, with additional guidance from the Program Manager and support from the Social Work Lead (SWL) at the clinic, the Social Worker is a key member of the Interdisciplinary Team (IDT). The role involves assessments, coordination, treatment planning, referrals, and connecting patients to community resources to meet their complex needs.DUTIES / RESPONSIBILITIES :Clinical Practices and Case ManagementUse independent judgment to manage a panel of patients.Conduct initial and ongoing psychosocial assessments to develop and update individualized care plans and interventions.Partner with caregivers and support systems to design care plans and deliver services.Identify risks and psychosocial issues.Advocate, refer, coordinate, and follow up on patient service needs promptly.Provide individual counseling and facilitate family conferences.Engage with the broader community to address patient needs.Assist with discharge planning when a patient exits the program.Lead patient and / or caregiver groups and participate in special events such as caregiver workshops.Interdisciplinary Team Member Roles and ResponsibilitiesServe as the primary liaison between patients, caregivers, the care team, and community resources.Collaborate with departments such as Health Plan and external community agencies.Follow ethical and legal standards of social work practices.Adhere to organizational policies, safety standards, and confidentiality requirements.Complete all required documentation promptly and accurately.Participate actively in team meetings, advocate for patient and caregiver needs, resolve team differences, and support team decisions.Contribute to the continuous improvement of social work services and system efficiency.Perform other related duties as assigned.QUALIFICATIONS :MSW degree from an accredited institution.Minimum of one year of experience working with frail or elderly populations.Experience working with diverse populations.Experience collaborating within an interdisciplinary team.Strong interpersonal skills and the ability to work cooperatively with team members.Excellent organizational skills, including task prioritization and follow-up.Strong written and verbal communication skills.Proficient in Microsoft Office and computer systems.Bilingual in Cantonese or Mandarin required.Experience with electronic health record systems (preferred).One year of post-MSW experience (preferred).One year of case management experience (preferred).Healthcare-related experience (preferred).RATES45.17 - $50.18 Per Hour
