HCBA Waiver Social Worker, MSW

Position Summary

Reporting to the HCBA Waiver Manager, and as a member of the Care Management Team, the Social Worker supports the development and monitoring of the plan of treatment for a caseload of Home and Community Based Alternatives Waiver Program participants and provides community-based (in-home, telehealth, and telephonic) evaluation of services to ensure the health, safety, and well-being of vulnerable and high-risk populations.

This includes supporting transfer coordination, discharge planning, and issuance of all appropriate authorizations for covered services as needed by members. This position provides social services support such as participant screening, case management, counseling, and referral.

• Responsible for the proactive management of acutely and chronically ill patients with the objective of improving health outcomes and costs by providing the social services support critical to delivering the participant plan of treatment that reflects a comprehensive needs assessment, intervention development, and support.
• Conducting a comprehensive health and psychosocial assessment of participants’ medical needs, diagnosis, functional and cognitive abilities, and environmental and social needs, working in conjunction with a registered nurse, to determine which service(s) are required to meet participants’ needs and preferences in the community.
• Working with the participants, their legal representatives, circles of support, and/or primary care physicians and providers to develop an effective Plan of Treatment (POT), including:
• Developing goals associated with the participant’s assessed needs, individual circumstances, and preferences.
• Mitigates risk and minimizes disruptions in services.
• Identifies when services in the POT are available through friends, family, and/or other publicly funded programs.
• Implement the POT, including identifying service providers and community resources to help assure the timely, effective, and efficient mobilization and allocation of the services.
• Identify (and arrange training, if necessary), backup caregivers who are willing and able to provide unpaid support if/when waiver service providers do not arrive when scheduled.
• Provide information, education, counseling, and advocacy to, and on behalf of, participants.
• Routine monitoring of the delivery and quality of HCBA Waiver services to ensure HCBA Waiver participants are receiving services as authorized in their POTs, including a monthly face-to-face visit or telephone call, to monitor for changes in health, mood, social integration, functionality, and overall well-being.
• Conducting routine annual face-to-face visits for HCBA Waiver Program participants, reassessments, and care plan updates; and, following up with the participant after Emergency Department and inpatient facility admissions.
• Develop resources and refer patients and families to appropriate community agencies or facilities, acts as liaison with such organizations and as advocate for participants.
• Maintain accurate HCBA Waiver Program case management records and timely documentation standards.
• Consult with and advise staff members as to the relationship of social, emotional, and cultural factors to health and medical care, and as to the availability of social services in the community.
• Maintains a working knowledge of facility service areas including transportation, community characteristics and geography.
• Maintains a networking liaison with other organizations to address a broad range of social service needs. May be requested to represent the agency in contact with human service, health care, and community organization groups and individuals.
• Attending meetings, teleconferences, and trainings; or ensure a knowledgeable proxy attends in the place of the program lead to ensure the transfer the information.
• Participates as a clinical consultant within the Homes Health Program to review and inform regarding the participants health action plan, act as clinical resource for care coordinators, as needed; and facilitate access to primary care and behavioral health providers, as needed to assist care coordinators.