Licensed Social Worker - Post-Acute And Transitional Care

Apply

Description

Community Health Centers of America is a premier multi-specialty group focused on improving the health of the community through excellence in clinical care and at partner care facilities. We are looking for an Licensed Social Worker to work full-time with us in our Fair Oaks office supporting the health program for partner care facilities throughout the Sacramento area.

The Licensed Social Worker supports CHCA's mission to serve the underserved by ensuring patients in post-acute and transitional care settings experience safe, timely, and supportive transitions to lower levels of care or community living. This role provides psychosocial support, resource connection, and care coordination for patients as they move between hospitals, skilled nursing facilities, residential care facilities, and home or outpatient care.

The Social Worker collaborates closely with CHCA's primary care, psychiatry, and care management teams to address barriers to care, support patient independence, and reduce avoidable readmissions.

Essential Functions and Responsibilities:

Patient Support and Transition Planning

• Conduct comprehensive psychosocial assessments for post-acute patients referred by CHCA providers or facilities.
• Develop individualized transition and care plans addressing social determinants of health, resource needs, and family/caregiver involvement.
• Coordinate services for housing stability, home health, hospice, DME, transportation, and medication management as needed.
• Serve as the primary liaison between SNF/RCFE staff, hospital discharge planners, CHCA clinic providers, and community agencies.
• Facilitate communication between patients, families, and healthcare teams to ensure continuity of care and understanding of post-discharge plans.

Care Coordination

• Monitor patients' progress through the post-acute episode and follow up after discharge to ensure connection to outpatient services.
• Identify high-risk patients and collaborate with the care management team to reduce readmissions.
• Participate in interdisciplinary care team meetings and case conferences.
• Maintain timely and accurate documentation within the EMR system

Community Resource and Advocacy

• Maintain up-to-date knowledge of community and county resources, including behavioral health, housing, food, and transportation programs.
• Provide education and advocacy for patients and families navigating Medi-Cal, SSI, IHSS, or other entitlement programs.
• Support facility staff and CHCA teams with resource navigation for complex cases.

Quality and Compliance

• Assist with data tracking and reporting for post-acute and transitional care quality metrics.
• Participate in QI initiatives to strengthen continuity of care and patient satisfaction.
• Ensure compliance with HIPAA, FQHC, and regulatory standards in all patient interactions

Work Environment

• Primarily field-based with regular visits to partnering post-acute facilities (SNFs, RCFEs, or transitional housing programs) and CHCA clinics.
• Some telehealth coordination and administrative documentation completed remotely or from CHCA offices.

Benefits

• Competitive salary with a full benefits package
• Medical, dental, and vision insurance
• CME allowance and paid educational leave
• Accrued vacation, paid holidays and sick time
• 401k with generous match
• Participation in the NHSC Loan Repayment Program (site approved)

Requirements

POSITION REQUIREMENTS

• Master's Degree in Social Work (MSW) from an accredited school of social work required.
• Active California LCSW or ACSW registration required.
• Minimum two years of experience in healthcare or community-based social work (FQHC, SNF, hospital, or managed care preferred).
• Knowledge of Medi-Cal, Medicare, and local county social service systems.
• Familiarity with HRSA enabling services framework and care coordination principles.
• Demonstrated cultural competence and commitment to serving diverse, underserved populations.
• Strong motivational interviewing skills.
• Experience in geriatric or long-term care settings
• Experience with case management and care coordination
• Ability to work independently and as part of a multidisciplinary team
• Proficiency in electronic health record (EHR) systems
• Skills in crisis intervention and conflict resolution
• Strong problem-solving abilities
• Commitment to ongoing professional development
• Knowledge of social work ethical standards and practices
• Strong organizational and time management skills, with the ability to manage multiple priorities efficiently
• Excellent communication and interpersonal skills to build rapport with residents, families, and healthcare professionals
• High level of attention to detail and accuracy in documentation and administrative tasks
• Proficiency in medical terminology, anatomy, and general medical conditions
• Ability to maintain confidentiality in accordance with HIPAA and other regulations
• Capacity to adapt to changing workloads and situations
• Valid driver's license with automobile insurance
• Able to do prolonged periods of sitting at a desk and working on a computer.
• Must be able to lift up to 15 pounds at times.

Salary Description

50.00 - 70.00/hour, depending on experience