D-SNP Social Worker

D-SNP Social Worker

Location : Candidates for this position must reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties).

Description :

The D-SNP Social Worker within the Care Management team helps our dual-eligible (D-SNP) members by addressing psychosocial and social-determinant needs and coordinating services across medical, behavioral health, LTSS, and community programs.

What You Will Do :

• Psychosocial Assessment and Care Planning :
• Conduct member-centered psychosocial assessments and reassessments, addressing behavioral health, functional status, caregiver needs, rehabilitation, and environmental / SDOH concerns.
• Evaluate holistically to identify functional limitations that affect independent living and safety.
• Develop and update individualized, person-centered care plans with the member / caregiver; set measurable goals and review after significant events (e.g., hospitalization).
• Recommend strategies to improve function, independence, and caregiver support.
• Participate in Interdisciplinary Care Team (ICT) activities, share updates, and ensure aligned follow-through on care plan goals.
• Consult with the Nurse Care Manager on medical issues; collaborate with pharmacists, behavioral health clinicians, PCPs, specialists, and community partners.
• Care Coordination and Transitions Support :
• Based on assessment findings, arrange, coordinate, and monitor services from medical, behavioral health, LTSS, and community providers.
• Facilitate warm handoffs and coordinate services during transitions (hospital - SNF - home / ALF), supporting follow-up appointments and community service linkages to reduce gaps in care.
• Conduct home visits as applicable to assess the living environment, safety risks, caregiver strain, and resource needs; document findings and actions.
• Refer to specialized programs as indicated (e.g., CCS, TCRC, County Behavioral Health / ADMHS, Public Health) and to complex medical case management when needs are primarily medical.
• Manage an active caseload, prioritize by risk / need, and deliver interventions within role scope.
• Resource Navigation and Advocacy :
• Identify and address home environment needs, including meal delivery, transportation, counseling referrals, in-home skilled / non-skilled services, and alternative living options.
• Connect members to benefits and programs (e.g., IHSS, HCBS / CBAS, housing and food support, transportation, utility assistance) and assist with applications and appointments as appropriate.
• Provide brief supportive interventions (e.g., problem-solving, motivational engagement) and crisis resource linkages; escalate safety concerns per policy.
• Supportive Interventions and Documentation :
• Document timely and accurately in the care-management system : assessments, care plans, outreach, referrals, ICT updates, and outcomes.
• Maintain HIPAA / confidentiality and follow all privacy, consent, and release-of-information procedures.
• Meet required turnaround times for outreach, documentation, and follow-up.
• Uphold high ethical standards; participate in continuing education to maintain current knowledge.
• Perform other duties as assigned.

You Will Be Successful If :

What You Will Bring :

About Impresiv Health :

Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.

Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do – provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.

That’s Impresiv!