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Integrated Care Management, Licensed Clinical Social Worker (LCSW)

Job ID SVH-2200185 Date Posted 01/06/2022 Location Mather, California Schedule/Shift Full Time/ Day
Position Overview:
The Sutter Care Coordination Case Manager, Licensed Clinical Social Worker (LCSW) or Clinical Social Worker, (MSW)participates in the assessment and case management of identified high-risk clients who are at clear risk of needing a higher level of care due to a serious and persistent chronic condition. The Sutter Care Coordinator Case Manager, Sutter Care Coordination Case Manager, Licensed Clinical Social Worker (LCSW) provides biopsychosocial assessment, crisis intervention, and linkage with resources for outpatients, their families and significant others.   Provides consultation and training on psychosocial aspects of care as a member of the interdisciplinary treatment team.  Serves as a liaison to community programs.  Provides psychosocial services for patients and family members.  Provides emotional support and education for staff.  Assists case managers with complex social situations.  Uses Motivational Interviewing techniques to identify patient/family strengths to be incorporated into problem solving interventions. Assess psychodynamic relationships between the patient/family environments to identify factors that hinder the problem solving process. Identify and mitigate system related factors both within the health care system and the community at-large. Develop ways of mitigating obstacles affecting care plan implementation and success.
The, Sutter Care Coordination Case Manager, Licensed Clinical Social Worker (LCSW) represents Sutter Health Sacramento Sierra Region as an integral part of the Interdisciplinary Sutter Care Coordination Case Management Team.
·         In a timely manner, gathers appropriate data and formulates relevant assessment of patient and family’s medical, social, and emotional situations using effective interviewing techniques, consultation with healthcare team and chart review.
·         Establishes and periodically revises the treatment plan on the basis of comprehensive and ongoing psychosocial assessment of patient/family's concerns, strengths, needs, clinical impressions, and issues specific to spiritual and cultural values. 
·         Appropriately gathers data reflective of the patient's and family's developmental stages.  Effectively incorporates data including age-specific needs into assessment and treatment planning for patients of all ages.
II.        Provides in-home assessments for at risk clients.
·         Provides in-home, assessment and/or telephone assessments and reassessment of high-risk clients as part of the interdisciplinary Sutter Care Coordination Case Management team.
·         Reviews assessments and presents client findings at bi-weekly case review with the Sutter Care Coordination team and develops appropriate care plans to meet client needs.
·         Refers clients to the appropriate community resources based on assessed needs.
·         Design plan of care for client using short & long term goals in conjunction with client, family and members of case management team.
I.                   Responsible for developing and providing care plans from a social work perspective for clients receiving Sutter Care Coordination Program Case Management.
·         Develops written or computerized care plans based on the client’s medical and functional needs assessment which includes clinical input from the Sutter Care Coordination Case Manager and/or the Primary Care Physician.
·         Presents and discusses care plans with clients and caregivers in the clients home or via telephone when necessary.
·         Provides overview of action items included in the care plan to the clients and family/caregivers.  Follow up is provided on a scheduled basis in order to facilitate and empower the client to follow through on the care plan and reassess.
·         Provides updated care plans for interdisciplinary team members review, responsible for communicating with other Sutter providers during period the client is receiving long term case management.
·         In a timely manner, gathers appropriate data and formulates relevant assessment of patient and family’s medical, social, and emotional situations using effective interviewing techniques, consultation with healthcare team and chart review.
·         Establishes and periodically revises the treatment plan on the basis of comprehensive and ongoing psychosocial assessment of patient/family's concerns, strengths, needs, clinical impressions, and issues specific to spiritual and cultural values. 
II.                Provides Case Management across the continuum of care for at risk clients based on their level of identified risk.
·         Based on individual client needs, arranges for appropriate services and agencies to provide care to at risk clients in order to insure efficient and high quality care.
·         Monitors and modifies care plans according to established protocols and procedures.
·         Mediates between the Sutter system, the client and other entities or individuals when care issues arise that are complex and long term in nature and/or when idiosyncratic needs must be considered in order to achieve positive outcomes.
·         Cross-refers to the Health Care Coordinator for periodic follow up when the client has reached an optimal functioning level.
III.             Coordinates current information and linkage to community services, respite and placement options.
·         Contacts Sutter entities and community agencies to verify availability and appropriateness of services for specific needs of clients.
·         Provides education to appropriate Sutter entities regarding the Sutter Care Coordination team’s focus, responsibility and need for linkage and interface (e.g., SVNA, SNFs, STCC).
·         Develops and maintains relationships with supportive community agencies.
IV.             Develops policies and procedures for the Sutter Care Coordination continuum of care.
·         Develops policies and procedures for telephone and home assessments.
·         Develops policies and procedures for managing quality assurance for care coordination.
·         Develops policies and procedures for recorded and data collection required by Sutter Care Coordination Program/ Case Management.
·         Develops policies and procedures related to data collection and tracking of outcome goals.
V.                Uses effective interpersonal and communication skills to promote a positive department image with internal and external customers.
·         Initiates and participates in consultative and collaborative relationships to enhance patient care.
·         Communicates significant information relating to the patient, his family, plan or care, or other planned events to appropriate health care personnel, payers, and administrators.
·         Discusses alternative plans for patient care with appropriate health care personnel.
·         Arranges family conferences/visits/appointments/medication refills and supplies as needed.
·         Responds to requests for consultation in a timely manner and documents interactions, assessments, and recommendations.
·         Seeks and provides peer consultation about cases that are problematic and/or present significant deviations from the plan of care.
·         Meets all applicable department standards for productivity, annual competency validation, safety education, licensure, and departmental performance/process improvement
·         Interprets clinical findings, promptly communicates assessment and treatment plan updates, and provides effective consultation on patient care issues to health care team and agency representatives,
adhering to confidentiality guidelines.
·         Responds quickly to requests, flexibly adapts to changing priorities, and keeps other departments informed of progress on patient referrals and other work activities to ensure efficient coordination of activities.  Coordinates with unit staff and colleagues to assure cases receive appropriate follow-up after the assignment of the per diem social worker ends.
·         Develops positive, productive relationships with healthcare team members and representatives of community agencies, effectively collaborating on process improvement activities and staff/community education.
VI.             Adheres to Sutter Health Central organizational policies and procedures.
Commitment to Quality:
·         Demonstrates commitment to total quality management through knowledge of its precepts, skillful workplace applications and continuous organizational improvement.
·         Exhibits a customer/supplier philosophy that emphasizes both internal and external relationships; identifies both customer and supplier needs/expectations and strives to exceed them.
·         Actively participates in, and encourages others to utilize creative and innovative approaches to accomplish tasks.
·         Demonstrates responsibility for ongoing personal development, professional growth and continuing education.
Planning and Time Utilization:
·         Performs duties in a self-directed manner with minimal supervision or direction.
·         Ensures that routine and priority tasks are completed within established departmental time frames.
Policies and Procedures:
·         Demonstrates a clear understanding of, and consistently adheres to department and facility policies and procedures.
·         Attends and actively participates in department and facility meetings and classes, including annual fire, safety, and disaster programs.
·         Follows safety procedures, operates equipment and performs job related duties in a safe manner which prevents accidents from occurring.
Attendance and Reliability:
·         Sick or absent time off does not exceed the facility guidelines as outlined in the Personnel Policy manual.
·         Provides proper notification of absence or tardiness within established departmental time frames.



  • Master's degree from a program accredited by the Council on Social Work Education.

Licensure / Certification / Registration:
  • If candidate is an LCSW, must have current California licensure in good standing as a Licensed Clinical Social Worker
  • If candidate is an MSW, candidate must have current registration as an Associate Clinical Social Worker; or obtain California registration as an Associate Clinical Social Worker within six months of employment, and continuous pursuit of LCSW until licensure is granted within three years of obtaining supervised hours
  • Valid California Drivers License.
  • Certified Case Manager (CCM) certification (through Commission for Case Manager Certification) or Accredited Case Manager (ACM) certification (through American Case Management Association) is preferred.
·        Strong clinical skills in biopsychosocial assessment, crisis intervention, counseling, interdisciplinary  collaboration and linkage with resources.
·         Knowledge of child, elder and dependent adult abuse and domestic violence reporting requirements and other significant regulations affecting clinical social work practice (e.g. Tarasoff, patient-psychotherapist privilege).
·         Knowledge of suicidal behavior, and the skills necessary to assess lethality, and to develop appropriate treatment plans
·         Masters in Social Work required with concentration in geriatric population preferred. 
·         Knowledge of managed care.
·         In-depth knowledge of geriatrics including common health & functional changes in the aged, and various chronic disease processes.
·         Knowledge of the process of long-term care and the private/public resources available to support the clients served.
Knowledge and understanding of human behavior and communication, psychotherapy, case management, and the influence of cultural and spiritual values in social work practice.
·         Experience in a healthcare setting is preferred.
·         Previous experience in community based health care.
·         Experience developing care plans.
·         Experience working as a member of a multi-disciplinary team.
·         Experience in in-home and telephone patient case management, knowledge of health related information, education, resource and referral services.
Special Skills/Equipment:
·         Ability to work respectfully and creatively with clients of diverse functional abilities, social, economic, and cultural backgrounds to support both client autonomy and client safety.
·         Demonstrated skills in motivating, mentoring, coaching and redirecting clients in order to achieve compliance with various necessary medical, social and functional interventions.
·         Ability to administer assessment testing and to create individual assessment protocols.
·         Word processing and data base management skills.
·         Computer skills.
·         Ability to type 45 cwpm.
·         Demonstrated ability to effectively communicate, both verbally and in writing.
·         Work is performed with many interruptions. 
·         Must demonstrate strong interpersonal and organizational skills, to work effectively in a fast-paced environment with rapidly changing priorities and competing demands.
·         Must be able to occasionally flex time to handle emergencies.

Organization:Sutter Valley Hospital
Employee Status: Regular
Employee Referral Bonus: No
Benefits: Yes
Position Status: Exempt
Union: No
Job Shift: Day
Shift Hours:8 Hour Shift
Days of the Week Scheduled:Monday-Friday
Weekend Requirements: None
Schedule: Full Time
Hrs Per 2wk Pay Period:80
Applications Accepted:All Applications Accepted
Additional Location: 600 Coffee Road, Modesto, California

Sutter Health Affiliates are equal opportunity employers EOE/M/F/Disability/Veterans

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