Responsible for the assessment of clients with multiple medical and psychosocial needs. Plans for and monitors services and interventions ensuring provision of quality care. SPECIFIC RESPONSIBILITIES: • Conducts comprehensive assessments and on-going re-assessments of the residents and including psychosocial, physical and mental health, environmental and spiritual needs. • Writes comprehensive assessments. Based on assessment information with the client develops and initiates the client-centered Community Living Plan. • Identifies arranges for and monitors appropriate community services based a good knowledge of Medicare, Medi-Cal, and other entitlement programs. • Establishes and maintains a care management relationship with clients and their significant others as appropriate, offering respect, dignity and support. Provides crisis intervention, advocacy, problem solving and therapeutic interventions. • Meets with clients at least monthly, and more often as needed. Reviews and modifies their Community Living Plan on an ongoing basis. • Documents via progress notes all case management activity regarding identified problems within 24 hours, adding any new problems to the service plan, as needed. • Maintains required paperwork and follows a clear, concise, and consistent system of charting to allow for continuity of care. • Educates clients and significant others about resources and when possible, trains them to provide their own case management. • Establishes and maintains open and effective communication with community providers, including physicians and other health care and social service workers. Provides appropriate information on all significant aspects of individual client care and program operations, while maintaining necessary confidentiality. • Monitors the quantity and quality of the services provided by other involved providers. • In collaboration with the client, caregiver, and involved services, terminates clients when appropriate. Documents the process as required. • Participates in research studies and data collection, as required. • Participates in and promotes ongoing efforts towards Continuous Quality Improvement. • Attends and actively participates in IOA and Santa Clara Methodist Retirement Foundation team and program meetings, activities and problem-solving endeavors; contributes to open lines of comunication within the teams. • Utilizes supervision appropriately; maintaining open lines of communication and providing updates on caseload activity. • Actively incorporates the ethical standards of the National Association of Social Workers into all aspects of interactions with others. • Understands and applies the regulatory and procedural requirements of Community Living Services as well as the policies and procedures of the Institute on Aging. • Attends continuing education classes and/or inservice training to increase knowledge, skills and attitudes related to case management, gerontology, family and community systems and other areas relevant to the client population. • All other reasonably related responsibilities as assigned. EDUCATION: B.A or B.S in Social Worker or related field required BACKGROUND AND EXPERIENCE: • One year's experience working with disabled adults and/or frail elderly required. • Experience with and understanding of the medical and psychosocial problems of functionally impaired adults and the frail elderly. • Bilingual highly preferred; English plus Cantonese and / or Mandarin and/or Spanish. • Exceptional communication and presentation skills relating to the frail elderly, functionally impaired adults, their support systems and teams of health professionals. • Demonstrates case management skills and experience in the community health care delivery system. • Detail oriented with good problem solving skills and the ability to prioritize multiple tasks. • Computer literacy required. PHYSICAL & LANGUAGE REQUIREMENTS: • Ability to lift up to 25 lbs. • Ability to reach, bend, and walk • Five finger manipulation • Ability to speak and write English clearly Compensation • Range: $73,233 - $87,525/annual This amount is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any specific employee, which is always dependent on actual experience, education and other factors. This range does not include any additional equity, benefits, or other non-monetary compensation which may be included. Institute on Aging reserves the right to revise job descriptions or work hours as required.