SUMMARY
Montage Medical Group's Collaborative Care Services (CCS) department supports patients and care teams in navigating the complex healthcare system with compassion, kindness, and reliability. We are trusted in our knowledge and follow through. We meet our patients where they are and advocate for their needs.Our team consists of Registered Nurse Care Managers, Licensed Vocational Nurse (LVN) Clinical Care Coordinators, Social Workers, Pharmacy Technicians and Care Coordinators.
The Social Worker brings specialized expertise to support individuals and families in addressing unmet health-related needs and life challenges. This role focuses on providing emotional support, advocacy, care coordination, and linking patients to critical community resources. Emphasis is placed on addressing the "social determinants of health" - the social and economic conditions impacting patients' physical and mental well-being. The Social Worker helps patients navigate barriers to accessing resources and supports them through significant life transitions. Services are typically offered for three to six months or until the goals are achieved or resources are maximized.
Essential Duties and Responsibilities
Key Responsibilities Include :
- Supporting Primary Care and Behavioral Health patients experiencing :
Abuse / self-neglect, including evaluation and mandated reporting
Domestic violenceHousing, food, and financial insecurityTransportation challengesChallenges applying for government assistance (e.g., Medi-Cal, CalFresh)Difficulty applying for disability benefitsDifficulty accessing VA benefits / servicesCaregiver / dementia-related challenges (e.g., burnout, long-term care planning, caregiver support)Difficulty accessing legal resourcesSocial isolationDifficulty accessing in-home caregiver servicesHealth insurance barriers (e.g., uninsured / underinsured, medical debt)Substance abuse and smoking cessation supportDifficulty accessing behavioral health services due to severe mental illnessConducting psychosocial assessments to evaluate :Educational, occupational, and financial status
Family dynamics, stressors, and support systemsSocial, cultural, health, and spiritual factorsProviding crisis intervention for patients with suicidal ideation.Maintaining communication with patients to address concerns and meet clinical treatment plan goals.Offering guidance, support, and access to resources to overcome barriers to care.Collaboration and Coordination :
Partnering with Emergency Department (ED), Transitional Care Management, and Complex Care Management teams as needed.Collaborating with healthcare professionals from other clinics within MMG.Working closely with the healthcare team to develop treatment and discharge plans based on psychosocial assessments.Participating in initiatives to improve methods for identifying and evaluating patient needs.Administrative Duties :
Maintaining knowledge of community resources and agencies in Monterey County.Ensuring accurate, complete, and timely documentation in the Electronic Health Record (EHR).Collecting and reporting required statistical data.Supervising the delegation of social support tasks to non-licensed, non-clinical care coordinators to optimize resource utilization.Supervisory Responsibilities
This position has no supervisory responsibilities.
Montage Values
Employees of Montage Medical Group are expected to uphold the Montage Values and Service Standards. Montage Medical Group employees find joy in caring for those we service, are dedicated to coordinating care across all settings, take ownership, collaborate to deliver the highest quality care and are entrusted to serve our community with respect.
Education
Required : Bachelor's degree in social work from a Council on Social Work Education-accredited institution.Preferred : Master's degree in social work.Experience
Preferred : Three to five years of social work experience.Certificates, Licenses, and Registrations
Preferred : Licensed Clinical Social Worker (LCSW) credential from the California Board of Behavioral Sciences.Required : Valid California driver's license and proof of minimum insurance coverage for travel between clinics.Skills and Abilities
Ability to effectively collaborate with physicians and healthcare staff.Ability to remain calm and effective during emergencies.Strong interpersonal skills to engage with patients, families, and colleagues.Adaptability to changing demands.Competence in planning, organizing, prioritizing, and directing tasks.Clear and effective communication skills.
