Social Worker; PHM- Bakersfield

Location: Bakersfield, CA (Onsite)

Classification: Full-Time

Schedule: Monday-Friday 8am-5pm

• Medical
• Dental
• Vision
• Paid Time Off (PTO)
• Floating Holiday
• Simple IRA Plan with a 3% Employer Contribution
• Employer Paid Life Insurance
• Employee Assistance Program

Compensation: The initial pay range for this position upon commencement of employment is projected to fall between $28.15 and $35.18. However, the offered base pay may be subject to adjustments based on various individualized factors, such as the candidate's relevant knowledge, skills, and experience. We believe that exceptional talent deserves exceptional rewards. As a committed and forward-thinking organization, we offer competitive compensation packages designed to attract and retain top candidates like you.

The Social Worker is responsible for addressing the clinical and non-clinical needs of members across the Population Health Management (PHM) continuum. The role focuses on supporting members with complex medical, behavioral, and social needs through person-centered care coordination, advocacy, and connection to health and community-based resources. Services may be provided telephonically, virtually, in clinics, or in members’ homes and communities, based on member preference and program requirements.

The Social Worker provides services and coordination with members to ensure continuity of care across health and social service programs, including community-based resources and long-term services and supports (LTSS). The Social Worker collaborates with an interdisciplinary care team (ICT) that includes case managers, clinicians, community health workers, and other professionals to ensure members receive coordinated, continuous care. The Social Worker supports members in addressing behavioral health and social needs, reducing barriers to care, and connecting to resources that promote wellness, stability, and self-management.

• Manage and maintain a caseload of PHM members, with a primary focus on those with behavioral health and social needs, while coordinating with the care team on medical needs as appropriate.
• Conduct comprehensive assessments and develop individualized, person-centered care plans in collaboration with members, caregivers, and providers.
• Support members with behavioral health needs, including serious mental illness (SMI) and/or substance use disorders (SUD) through linkage to appropriate services.
• Provide culturally appropriate education to members and caregivers regarding behavioral health, chronic disease self-management, and community resources.
• Track member outcomes and document all encounter, interventions, and care plan updates in the Case Management (CM) system in compliance with organizational standards.
• Build and maintain collaborative relationships with providers, community agencies, and social service organizations to facilitate referrals and care coordination.
• Engage members using evidence-based approaches such as Motivational Interviewing to promote collaboration, increase member activation, and improve self-management skills.
• Provide brief crisis intervention and warm hand-offs to appropriate resources as needed.
• Support transitional care services by coordinating discharge planning, scheduling post discharge provider or TOC Clinic appointments, reconciling social/behavioral needs, and connecting members to ongoing supports to reduce avoidable readmissions and ER visits.
• Provide navigation and coordination of long-term services and supports (LTSS), ensuring members and caregivers are connected to appropriate programs that promote independence, stability, and quality of life.
• Address members’ social determinants of health (SDOH) by identifying needs such as housing, food insecurity, transportation, financial instability, or caregiver support, and facilitating access to community-based resources and services.
• Support members in strengthening skills that enable them to manage their conditions, identify and access needed resources, prevent complications, and maintain independence.
• Ensure care is continuous and integrated among all service providers by coordinating and following…