Social Worker

Position: Social Worker Job Summary: The Client Social Worker manages a caseload of participants, collaborating closely with the Client Interdisciplinary Team (IDT). This role involves providing essential social work services such as psychosocial assessments, care planning, counseling, and case management. Additionally, the Social Worker serves as a liaison between participants, their families, the IDT, and other members of the support network. This role requires a commitment to Client values, team culture, and mission. Key Responsibilities: Conduct comprehensive Social Work assessments to identify participants' psychosocial needs, preferences, and goals, actively contributing to care plans in IDT meetings. Implement and document social work interventions in alignment with care plans, including arranging resources and services, aiding in care transitions, and providing counseling and case management. Collaborate with the PACE Physician and IDT members to ensure seamless transitions between care settings (e.g., hospitals, skilled nursing facilities, home). Maintain awareness of relevant feedback from team members, participants, and caregivers, promptly updating the IDT on any changes in participants' condition or psychosocial status. Support enrollment of new participants in coordination with the Intake team. Lead care conference meetings to enhance coordination among PACE IDT members, participants, and support networks, including families and caregivers. Manage discharge planning for participants who disenroll from the program. Provide educational sessions on psychosocial aging issues to staff, participants, and families. Coordinate and support end-of-life care as needed. Conduct home visits as required. Assist benefits eligibility staff with Medi-Cal and Medicare enrollment processes. Ensure reliable transportation within the assigned territory to facilitate home visits. Work within the bounds of authority as legally authorized and as defined by the position’s location. For unlicensed Social Workers, limit services to those not requiring a license per Business and Professions Code section 4996. Complete all required documentation accurately and on time. Uphold privacy and confidentiality standards for company procedures and participant information. Adhere to Client policies and actively participate in Quality Improvement initiatives, training, and meetings. Regularly communicate workload and priorities with the Supervisor and team. Skills and Experience: Required: Minimum of one year’s experience working with a frail or elderly population. Strong clinical, organizational, and communication skills for working with frail, elderly participants, their families, and interdisciplinary team members. Experience coordinating and leading care conferences. Ability to problem-solve complex psychosocial and family issues. Highly motivated and self-directed, capable of handling tasks in a fast-changing environment and making sound decisions in emergencies. Proven ability to prioritize in a dynamic setting. Experience working with diverse populations and a commitment to supporting vulnerable seniors. Preferred: Experience working with individuals with behavioral health or substance abuse challenges. Education: Required: Master’s degree in social work (MSW) Preferred: Social Work Licensure