| Duties: |
Job Summary:
The Client Social Worker is responsible for managing a caseload of participants working in close coordination with the Client Interdisciplinary Team (IDT). In addition to delivering standard social work services such as psychosocial assessments, care planning, counseling and case management, the Social Worker functions as a liaison between the participants, their family members, the IDT, and other members of the participants. support network, as appropriate. Collaborates effectively with colleagues and stakeholders to promote the Client values, team culture and mission.
Duties and Responsibilities:
-Conduct Social Work assessments to determine the psychosocial needs, preferences and goals of the participants and actively participate in IDT meetings to develop participant care plans.
-Deliver and document social work interventions as agreed upon in the participants care plans including but not limited to arranging necessary resources and services, assisting with care transitions, providing individual and group counseling and case management.
-Work with the PACE Physician and other members of the IDT to support smooth care transitions between settings (e.g., hospitals, skilled nursing facilities, home, etc.).
-Remain alert to pertinent input from other team members, participants, and caregivers and update the IDT promptly of any changes in participants condition or psychosocial status.
-In coordination with the Intake team, facilitate enrollment of prospective participants into the program.
-Initiate, coordinate and facilitate care conference meetings to ensure the highest level of care coordination among PACE IDT members. participants and other people within the participants support network (family, informal caregivers etc.)
-Provides discharge planning when participants disenroll from the program.
-Provides educational in-services to staff, participants, and caregivers/families regarding psychosocial aspects of aging and related issues.
-Participate in end-of-life care coordination and support.
-Conduct home visits, as necessary.
-Provide support with Medi-Cal and Medicare enrollments to benefits eligibility staff.
-Must have reliable transportation to travel to participants homes within assigned territory, is required.
-Be legally authorized to perform in position location, required.
-Only act within the Product of his or her authority to perform.
-An unlicensed Social Worker shall only provide those social work services for which no license is required under Business and Professions Code section 4996.
-Complete all required documentation in a timely and accurate manner.
-Protect privacy and maintain confidentiality of all company procedures and information about team members, participants, and families.
-Follow Client policies and procedures and participate in any required Quality Improvement activities, staff training and meetings.
-Communicate regularly with Supervisor and team regarding workload and priorities.
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| Skills: |
Required Skills & Experience:
Minimum of one year of experience with a frail or elderly population.
-Excellent clinical, organizational, and communication skills in settings with frail, elderly participants, their families, and interdisciplinary team members.
-Experience coordinating and facilitating care conference meetings.
-Ability to facilitate problem-solving with challenging psychosocial and family situations.
-Highly motivated, self-directed, able to execute tasks in a quickly changing environment and make sound decisions in emergency situations.
-Excellent organizational and communication skills.
-Ability to work independently with minimal supervision.
-Demonstrated ability to prioritize in a fast-paced environment.
-Experience and competency working with people from diverse backgrounds and cultures.
-Commitment to unlocking the full potential of our most vulnerable seniors.
Preferred Skills & Experience:
-Experience supporting individuals with behavioral health and substance abuse issues.
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