Integrated Transitional Care Manager, Lcsw/Lmft (Hybrid Work Schedule)

Under the direction of the Supervisor, Integrated Transitional Care, this position focuses on a person-centered model of care which takes in to account the Member’s medical, behavioral, and social needs. The Integrated Transitional Care (ITC) Team will provide services to all Medi-Cal Members transitioning to and from hospitals, institutions, other acute care facilities, and skilled nursing facilities to home or community-based settings. 
As a licensed behavioral health clinician, the individual in this position is to utilize their clinical expertise to support and engage Members to promote positive health behaviors, assist with coordination of care, provided resource linkages, and collaborate with other Team Members of this integrated care team, as well as facility partners, to ensure a seamless transitions of care experience.  The ITC LCSW will act as a Care Manager for care transitions and collaborate with the ITC team members to provide Transitional Care services to Members transitioning from one care setting to the next.
 

1. Assist Members with care coordination needs, including, but not limited to the following:
    a. Conduct comprehensive, holistic assessment both telephonically as well as in person (facility or home visits).
    b. Assimilate assessment information to assist, in collaboration with the ITC Team and the facility, in developing a discharge plan.  
    c. Communicate discharge plan with Member, approved family or caregiver and other Members of the care team.
    d. Coordinate with internal and external health partners to support Members’ comprehensive care needs.
2. Model the highest ethical behavior in care for Members, as well as in relationships with co-workers, Leaders, internal, and external partners.  
3. Advocate for Members to receive the highest quality care, in a timely manner, within IEHP’s network by referring to appropriate internal partners such as behavioral health, Enhanced Care Management, and complex care management.
4. Provide Transitional Care services to Members transitioning from one care setting to the next such as assisting the Member with PCP appointments, transportations, and coordination of DME and home health.
5. Support Member through all care transitions by making outreach to ensure all care needs are met before closing the Member out to transitions of care. providing care coordination, linkage to resources, and facilitating Member self-efficacy and self-management.  
6. Participate in Integrated Transitional Care Team meetings, Interdisciplinary Care Conferences, and any other meetings as required.  
7. Model continuous quality improvement philosophy and engage in quality improvement initiatives and projects.
8. Model supportive and collaborative relationships with Members, co-workers, facility partners, and community providers.
9. Engage in all IEHP Team Member training and comply with all IEHP policies. 

Minimum of three (3) years of experience performing Behavioral Health/Medical Social Work services. Experience in motivational interviewing and/or other evidenced-based communication strategies.

Behavioral Health/Medical Social Work services experience in a health clinic psychiatric hospital, medical facility, or health care clinic strongly preferred. Experience in clinical services, both mental health and substance use preferred. 

Master’s degree in Social Work from an accredited institution required.

Possession of an active, unrestricted, and unencumbered Clinical Social Worker (LCSW) license or Marriage and Family Therapist (LMFT) license issued by the California Board of Behavioral Sciences required.

Familiarity with Managed Care and discharge planning is required. Knowledgeable and skilled in evidenced-based communication such as Motivational Interviewing, or similar empathy-based communication strategies. Understanding of and sensitivity to multi-cultural communities. Deep understanding and knowledge of mental health and substance use conditions, including both acute and chronic management. Awareness of the impact of unmitigated bias and judgement on health; commitment to addressing both.  Must have knowledge of whole health and integrated principles and practices.
 

Bilingual (English/Spanish) preferred.
Highly skilled in interpersonal communication, including conflict resolution.  Effective written and oral communication skills, as well as reasoning and problem-solving skills.  Skillful in informally and formally sharing expertise. Must have the resiliency to tolerate and adapt to a moderate level of change and development around new models of care and care management practices. Proficient in the use of computer software including, but not limited to, Microsoft Word, Excel, PowerPoint.  Demonstrated proficiency with all electronic medical management systems (e.g., Cisco, MHK/Care Prominence, MediTrac, SuperSearch and Web Portal) is preferred.

Proven ability to:
- Sufficiently engage Members and providers on the phone as well as in person.
- Work as a member of a team, executing job duties and making skillful decisions within one’s scope.
- Establish and maintain a constructive relationship with diverse Members, Leadership, Team Members, external partners, and vendors.
- Prioritize multiple tasks as well as identify and resolve problems. 
- Have effective time management and the ability to work in a fast-paced environment.
- Be extremely organized with attention to detail and accuracy of work product. 
- Have timely turnaround of assignments expected.
- To form cross-functional and interdepartmental relationships. 

The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.
 

May include hours outside of typical business hours if needed to support regulatory compliance or quality projects.
Position is eligible for Hybrid work location upon completing the necessary steps and receiving HR approval. All IEHP positions approved for telecommute or Hybrid Work locations may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership.