Social Worker/Care Manager III (2100)

Community Living Services- San Francisco San Francisco, California


You may think “old” when you think of Institute on Aging (“IOA”) because we offer services for seniors and are a 40+ year institute…. but you wouldn’t be more wrong. While we do have a long-standing history in California, IOA is on the forefront of revolutionary healthcare models, reshaping the way people can age in place. Our innovative models transform lives, enhance communities, and save healthcare systems millions of dollars. Rather than focusing on archaic outdated design, we strive to consistently question the “status-quo” and create new and more innovative ways to help aging adults maintain their quality of life. With over 23 programs, we offer multiple ways to aid seniors maintain their health, well-being, independence and participation in the community, fulfilling our mission.

CLS is an innovative and revolutionary healthcare model that allows seniors to live at home longer by transitioning them out of nursing homes and back into the community by partnering with health plans and Medi-Cal. This inventive, nationally recognized model is one of the most promising for seniors to date, transforming their lives by providing them with a higher quality and more independent life and saving millions of dollars for healthcare systems. CLS is IOA’s fastest growing division, expanding throughout California.  Its employees are dedicated and forward-thinking professionals with a passion for building seniors a better world.

The CLF program assists with the transition of individuals with limited incomes out of skilled nursing facilities back into the community. CLF also provides services to individuals living in the community who are at imminent risk of institutionalization. CLF is administered in collaboration with Catholic Charities, Conard House, Self Help for the Elderly, and the San Francisco Department of Aging and Adult Services.

IOA's Community Living Fund team is seeking a Social Worker/Care Manager III for its team.  The primary responsibility of the Social Worker/Care Manager III is to provide case management services for a caseload of 17-22 Community Living Fund (CLF) clients.  The Care Manager III also plans for, and monitors services and interventions ensuring provision of quality care.  Additional key duties and responsibilities of the position include, but many not be limited to:

  • Provides mentorship, consultation, and training for all new CLF CM staff and interns.
  • Assumes case management responsibility for some of the program’s most complex clients.
  • Participates in CLF Leadership meetings a minimum of twice monthly.
  • Accepts program development projects as assigned.
  • Creates an intensity categorization scale to systematically improve caseload balance.
  • Acts as an ambassador for CLF promoting referrals and representing the team in community meetings with integrity and professionalism.
  • Facilitates CM Development Program by identifying, scheduling, and coordinating monthly presenters.
  • Implements CLF Policy & Procedure Manual revision recommendations on an annual basis.
  • Participates in hiring process by scheduling interviews, preparing interview questions, and providing hiring recommendation feedback.
  • Acts as a surrogate approver for CSBG time study as needed, ensuring double billing with MediCal waiver programs has not occurred.
  • Acts as a liaison between CLF and providers serving large numbers of CLF clients such as primary care clinics, housing organizations, etc.
  • Conducts comprehensive assessments and on-going re-assessments of the client including psychosocial, physical and mental health, environmental and spiritual needs.
  • Writes comprehensive assessments.  Based on assessment information with the client develops and initiates the Community Living Plan, which is client-centered, comprehensive and consistent with program guidelines and policies and procedures.
  • Conducts home visits, acute hospital & skilled nursing facility visits, as well as escorts clients to medical and other appointments as clinically indicated.
  • Establishes and maintains a care management relationship with clients and their informal support network as appropriate, offering respect, dignity and support. Provides crisis intervention, advocacy, problem solving, and therapeutic interventions.
  • Identifies, arranges for, and monitors appropriate community services based on a good knowledge of Medicare, Medi-Cal, and other entitlement programs.
  • Meets with clients at least monthly, and more often as clinically indicated.  Reviews and modifies their Community Living Plan on an ongoing basis.
  • Documents via progress notes all case management activity regarding identified problems within 24-48 hours, adding any new problems to the Community Living Plan, as needed.
  • Maintains required paperwork and follows a clear, concise, and consistent system of charting to allow for continuity of care.
  • Ongoing evaluation for client Purchase of Service needs and follow-up to determine if services have been provided in a timely manner.
  • Educates clients and informal support network about resources.
  • 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.
  • Working closely with the team, continuously evaluates the clients’ ability to remain safely at home; coordinates placement as appropriate, according to program guidelines.
  • 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.
  • Utilizes supervision appropriately; maintaining open lines of communication and providing updates on caseload activity.
  • Actively incorporates the ethical and legal 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 Fund as well as the policies and procedures of 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 Community Living Fund client population.
  • All other reasonably related responsibilities as assigned.


  • M.S.W (Master's in Social Work) Degree
  • Two years working with disabled adults and/or older adults required.
  • Experience with and understanding of the medical and psycho-social problems of functionally impaired adults and older adults.
  • One year’s experience working within a community-based case management program with a similar target population.
  • Experience working with individuals with mental and/or behavioral health diagnoses and substance abuse disorders highly desired.
  • Exceptional communication and presentation skills relating to functionally impaired adults and older adults, their support systems and teams of health professionals.
  • Demonstrates case management skills and experience in the community health care delivery system.


  • Experience working with individuals with mental and/or behavioral health diagnoses and substance use disorders

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Institute on Aging reserves the right to revise job descriptions or work hours as required.

Institute on Aging is an Equal Opportunity Employer. Institute on Aging is committed to cultivating a diverse and inclusive work environment and providing equal opportunities to all employees and job applicants without regard to age, race, religion, color, national origin, sex, sexual orientation, gender identity, genetic disposition, neuro-diversity, disability, veteran status or any other protected category under federal, state and local law.