Social Services Coordinator

Primary Job Duties and Responsibilities:

• Identify, screen, and assess social determinants of health (SDOH) needs for referred patients.
• Assist with end-of-life planning and Durable Power of Attorney (DPOA)/Physician Orders for Life-Sustaining Treatment (POLST), VA benefits coordination, and hospice and palliative care referrals as deemed necessary.
• Navigate and facilitate enrollments, referrals, and applications for key county and state programs, including Medi-Cal, Community-Based Adult Services (CBAS), In-Home Supportive Services (IHSS), CalFresh, housing navigation, and local supportive services across San Bernardino County.
• Build, maintain, and expand working relationships with local community-based organizations (CBOs), county health agencies, and social service providers.
• Assist in developing and maintaining collaborative relationships with community medical/healthcare services and social services agencies.
• Assist patients and family caregivers with completing necessary administrative paperwork, applications, and appeals processes for public assistance programs.
• Delegated Medicare Advantage Lines: Coordinate directly with the internal behavioral health team and primary care providers to manage mental health and substance use care plans for Medicare Advantage members.
• Non-Delegated Lines (Commercial, Covered California, Medi-Cal): Serve as the dedicated operational liaison to external health plan case management teams and county agencies (e.g., San Bernardino County Department of Behavioral Health) to request authorizations, facilitate care transitions, and coordinate care for members requiring non-delegated behavioral health care.
• Connect patients with resources that may include outpatient or inpatient behavioral health, substance use for detox/rehab, or other resources because of inadequate support system, lack of appropriate resources or understanding of their medical benefits.
• Participate in multidisciplinary care team meetings and interdisciplinary care staffing to ensure seamless integration of physical, social, and behavioral health care.
• Receive and triage incoming social services referrals from primary care providers, urgent care clinics, inpatient navigators, and case management staff.
• Document all assessments, patient encounters, plan coordination, resource connections, and follow-ups accurately in the Electronic Health Record (EHR) in accordance with department standards and compliance timelines.
• Monitor resource delivery and perform timely follow-ups to verify that services were successfully rendered and barriers were resolved.
• Support department quality, health equity, readmission reduction, and care transition performance metrics.
• Perform other duties as assigned.

The pay range for this position at commencement of employment is expected to be between $26.61 and $28.35/hour; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, skills, and experience. The total compensation package for this position may also include other elements, including a sign-on bonus, restricted stock units, and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered. Details of participation in these benefit plans will be provided if an employee receives an offer of employment.

Qualifications:

• Education: Bachelor’s degree in social work (BSW) or an equivalent degree in a related human services field (e.g., Psychology, Human Services, Sociology) required.
• Experience: Minimum 1–2 years of healthcare, case management, or social services experience preferred.
• Experience: Demonstrated knowledge of San Bernardino County community resources, Medi-Cal waiver programs, CBAS, and IHSS application pathways required.
• Experience: Understanding of delegated vs. non-delegated health plan delegation models across Medicare Advantage, Commercial Exchange, and Medi-Cal lines of business.
• Experience: Direct experience navigating substance use disorder (SUD) treatment pathways and county mental health resources preferred.
• Knowledge: Microsoft Office
• Skills: Excellent verbal and written communication skills, critical thinking
• Experience: Electronic Medical Records
• Skills: Ability to handle and prioritize tasks in order to meet all given deadlines and productivity goals.
• Skills: Ability to responsibly handle matters of a confidential nature.
• Skills: Ability to work in a multi-task, high-stress, environment.
• Driving: Current California driver’s license and proof of auto insurance.
• Other: At the discretion of HVVMG management, this position has the potential to be a full or hybrid telecommuting position.