Integrated Transitional Care Manager, MSW

What You Can You Expect?

Find joy in serving others with IEHP! We welcome you to join us in "healing and inspiring the human spirit" and to pivot from a "job" opportunity to an authentic experience!

Join the Integrated Transitional Care Team! As an ITC MSW, you'll be a key player using ensuring seamless transitions for IEHP Members. Conduct assessments, craft discharge plans, and coordinate with internal and external partners. Be the advocate for top-tier care, connecting Members with appropriate services. From face-to-face visits to resource assistance, you'll champion Member's needs. In meetings and daily actions, model the highest ethical standards and collaborative relationships.

Major Functions (Duties and Responsibilities)

1.Assist Members with care coordination needs, including, but not limited to the following:

a. Perform facility and home visits as needed to engage Member and obtain Member history and other information to assist in discharge planning.

b. Develop a discharge plan in collaboration with the Integrated Transitional Care Team and the facility.

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, county agencies, and community-based organizations to support Members' comprehensive care needs.

e. Assist Member with resources such as IHSS, CBAS, MSSP, behavioral health, including substance abuse treatment, assistive devices, etc.

f. Refer Member, as appropriate, for Community Supports Services provided under CalAIM (e.g., Medically Tailored Meals, Housing Transition and Navigation, Asthma Remediation, etc.

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 making appropriate referrals to Behavioral Health, Enhanced Care Management, and Complex Care Management.

4.Support Member through all care transitions by providing transitional care services such as Member outreach, face to face visits, providing care coordination, linkage to resources, and facilitating Member self-efficacy and self-management.

5.Participate in Integrated Transitional of Care Team meetings, Interdisciplinary Care Conferences, and any other meetings as required.

6.Model continuous quality improvement philosophy and engage in quality improvement initiatives and projects.

7.Model supportive and collaborative relationships with Members, co-workers, facility partners, and community providers.

8.Engage in all IEHP Team Member training and comply with all IEHP policies.

Commitment to Quality: The IEHP Team is committed to incorporate IEHP's Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Perks!

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.

• Competitive salary.

• Hybrid schedule.

• CalPERS retirement.

• State of the art fitness center on-site.

• Medical Insurance with Dental and Vision.

• Life, short-term, and long-term disability options

• Career advancement opportunities and professional development.

• Wellness programs that promote a healthy work-life balance.

• Flexible Spending Account - Health Care/Childcare

• CalPERS retirement

• 457(b) option with a contribution match

• Paid life insurance for employees

• Pet care insurance

Education & Requirements

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

• Minimum of three (3) years of experience in a Behavioral Health/Medical Social Work setting.

• Experience in motivational interviewing and/or other evidenced-based communication strategies.

Key Qualifications

• 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.

• 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.

Start your journey towards a thriving future with IEHP and apply TODAY!