Neighborhood Healthcare
Social Worker-PACE Program (Murrieta)
Neighborhood Healthcare, Murrieta, California, us, 92564
Community health is about more than just vaccines and checkups. It’s about giving people the resources they need to live their best lives. At Neighborhood, this is our vision. A community where everyone is healthy and happy. We’re with you every step of the way, with the care you need for each of life’s chapters. At Neighborhood, we are Better Together.
As a private, non-profit 501(C) (3) community health organization, we serve over 350k medical, dental, and behavioral health visits from more than 77k people annually. We do this in pursuit of our mission to improve the health and happiness of the communities we serve by providing quality care to all, regardless of situation or circumstance.
We have been doing this since 1969 and it is our employees that make this mission a reality. Regardless of the role, our team focuses on being compassionate, having integrity, being professional, always collaborating, and consistently going above and beyond. If that sounds like an organization you want to be a part of, we would love to have you.
ROLE OVERVIEW and PURPOSE
The Social Worker will manage a caseload of participants by providing a psychosocial perspective to the interdisciplinary evaluation, assessment, plan of care, ongoing services, and disenrollment processes of the PACE program at Neighborhood Healthcare (Neighborhood). This role will collaborate with the interdisciplinary team to optimize the health status and quality of life of Neighborhood PACE participants. Additionally, this role will liaise between participants, members of participants’ support network, and the interdisciplinary team.
RESPONSIBILITIES
Works with the PACE Interdisciplinary Team (IDT) to conduct initial, semi-annual, unscheduled, and annual assessmentsProvides participant health status updates to appropriate staff in daily meetingsObtains extensive psychosocial history from participants and/or family members upon admission to program and intermittently at pre-enrollmentCoordinates, schedules, and facilitates family conferences in conjunction with the PACE IDT to address levels of care, medication/treatment non-compliance, out-of-home placement, complex diagnoses, behavioral concerns and contracts, conditions of involuntary disenrollment, and alternative program optionsDevelops and facilitates various group counseling topics designed to assist at-risk populations over the age of 55 with chronic health conditionsProvides individual caregiver and family support counseling, as neededCoordinates with participants, family/caregivers, and primary care providers to complete advance life planning documents, assist with end-of-life planning, and provide educational resourcesConducts independent risk and safety assessments at skilled nursing facilities, residential care facilities for the elderly, assisted living facilities with/without memory care units, hospitals, and in-home, as neededScreens and develops share of cost for out-of-home placements based on financial documentation from participants and family membersCreates and executes supportive housing forms with care facilities and family members,Conducts intermittent and annual income reviews to update supportive housing forms and share of costsSchedules, coordinates, and accompanies participants and family members with transportation and admission to higher level of care to promote safety and continuity of care in cases of high acuityImplements hospice and palliative care services by providing referral documentation, coordination, education, and support to participants and familiesCommunicates with hospitals/skilled nursing facilities and utilizes external medical records systems to coordinate tailored discharge planning for participantsAssists with ongoing financial eligibility for participants, including Medi-cal recertifications, as neededLiaises effective connections and communications with other organizations in the eldercare fieldProvides support and education to staff members in areas of social, emotional, and cultural factors in the participant population, including how these factors relate to health, medical care, and the availability of social services in the communitySchedules, coordinates, and conducts in-home visits and assessments independently and in conjunction with the PACE IDT, as neededProvides redirection and support for participants with behavioral needs during PACE Day Center attendance, utilization of PACE transportation, and use of other PACE servicesRefers participants and families to appropriate community agencies and facilities while acting as an advocate and liaison with such organizationsConducts discharge planning to promote continuity of care in the event of disenrollmentsMaintains federally compliant and timely documentation of institutionalizations, Adult Protection Service reports/follow-ups and consultations, community contacts, family conferences, assessments, and other case management notes in medical recordsAttends required staff meetings/trainings and voluntary professional development coursesEDUCATION/EXPERIENCE
Master’s degree in social work requiredBLS (Basic Life Support) required prior to hire dateOne year experience working with frail or elderly populations requiredOne year of social work experience preferredExperience working in a community-based setting or geriatric program preferredBilingual (English/Spanish) preferredADDITIONAL QUALIFICATIONS (Knowledge, Skills, and Abilities)
Excellent verbal and written communication skills, including superior composition, typing and proofreading skillsAbility to interpret a variety of instructions in written, oral, diagram, or schedule formKnowledgeable about and experience with counseling theories and techniquesKnowledgeable about and experience with community resources for individuals and familiesAbility to establish and maintain good interpersonal relationshipsAbility to successfully manage multiple tasks simultaneouslyExcellent planning and organizational abilityAbility to work as part of a team as well as independentlyAbility to work with highly confidential information in a professional and ethical mannerPhysical Requirements
Ability to lift/carry 10 lbs/weightAbility to stand for long periods of time
Neighborhood Healthcare offers a generous benefit plan that includes: Partially company paid Medical, Dental, and Vision Plans. Two plus weeks of vacation, Nine Holidays including two Floating Holidays of your choosing, Sick/Personal time, Volunteer Time Off (VTO), 403b Retirement plan (similar to a 401k), optional Health and Wellness events, and much more!
Pay range: $80,600.00 - $92,560.00 annually, depending on experience. (Exempt position)
#NHCN23
As a private, non-profit 501(C) (3) community health organization, we serve over 350k medical, dental, and behavioral health visits from more than 77k people annually. We do this in pursuit of our mission to improve the health and happiness of the communities we serve by providing quality care to all, regardless of situation or circumstance.
We have been doing this since 1969 and it is our employees that make this mission a reality. Regardless of the role, our team focuses on being compassionate, having integrity, being professional, always collaborating, and consistently going above and beyond. If that sounds like an organization you want to be a part of, we would love to have you.
ROLE OVERVIEW and PURPOSE
The Social Worker will manage a caseload of participants by providing a psychosocial perspective to the interdisciplinary evaluation, assessment, plan of care, ongoing services, and disenrollment processes of the PACE program at Neighborhood Healthcare (Neighborhood). This role will collaborate with the interdisciplinary team to optimize the health status and quality of life of Neighborhood PACE participants. Additionally, this role will liaise between participants, members of participants’ support network, and the interdisciplinary team.
RESPONSIBILITIES
Works with the PACE Interdisciplinary Team (IDT) to conduct initial, semi-annual, unscheduled, and annual assessmentsProvides participant health status updates to appropriate staff in daily meetingsObtains extensive psychosocial history from participants and/or family members upon admission to program and intermittently at pre-enrollmentCoordinates, schedules, and facilitates family conferences in conjunction with the PACE IDT to address levels of care, medication/treatment non-compliance, out-of-home placement, complex diagnoses, behavioral concerns and contracts, conditions of involuntary disenrollment, and alternative program optionsDevelops and facilitates various group counseling topics designed to assist at-risk populations over the age of 55 with chronic health conditionsProvides individual caregiver and family support counseling, as neededCoordinates with participants, family/caregivers, and primary care providers to complete advance life planning documents, assist with end-of-life planning, and provide educational resourcesConducts independent risk and safety assessments at skilled nursing facilities, residential care facilities for the elderly, assisted living facilities with/without memory care units, hospitals, and in-home, as neededScreens and develops share of cost for out-of-home placements based on financial documentation from participants and family membersCreates and executes supportive housing forms with care facilities and family members,Conducts intermittent and annual income reviews to update supportive housing forms and share of costsSchedules, coordinates, and accompanies participants and family members with transportation and admission to higher level of care to promote safety and continuity of care in cases of high acuityImplements hospice and palliative care services by providing referral documentation, coordination, education, and support to participants and familiesCommunicates with hospitals/skilled nursing facilities and utilizes external medical records systems to coordinate tailored discharge planning for participantsAssists with ongoing financial eligibility for participants, including Medi-cal recertifications, as neededLiaises effective connections and communications with other organizations in the eldercare fieldProvides support and education to staff members in areas of social, emotional, and cultural factors in the participant population, including how these factors relate to health, medical care, and the availability of social services in the communitySchedules, coordinates, and conducts in-home visits and assessments independently and in conjunction with the PACE IDT, as neededProvides redirection and support for participants with behavioral needs during PACE Day Center attendance, utilization of PACE transportation, and use of other PACE servicesRefers participants and families to appropriate community agencies and facilities while acting as an advocate and liaison with such organizationsConducts discharge planning to promote continuity of care in the event of disenrollmentsMaintains federally compliant and timely documentation of institutionalizations, Adult Protection Service reports/follow-ups and consultations, community contacts, family conferences, assessments, and other case management notes in medical recordsAttends required staff meetings/trainings and voluntary professional development coursesEDUCATION/EXPERIENCE
Master’s degree in social work requiredBLS (Basic Life Support) required prior to hire dateOne year experience working with frail or elderly populations requiredOne year of social work experience preferredExperience working in a community-based setting or geriatric program preferredBilingual (English/Spanish) preferredADDITIONAL QUALIFICATIONS (Knowledge, Skills, and Abilities)
Excellent verbal and written communication skills, including superior composition, typing and proofreading skillsAbility to interpret a variety of instructions in written, oral, diagram, or schedule formKnowledgeable about and experience with counseling theories and techniquesKnowledgeable about and experience with community resources for individuals and familiesAbility to establish and maintain good interpersonal relationshipsAbility to successfully manage multiple tasks simultaneouslyExcellent planning and organizational abilityAbility to work as part of a team as well as independentlyAbility to work with highly confidential information in a professional and ethical mannerPhysical Requirements
Ability to lift/carry 10 lbs/weightAbility to stand for long periods of time
Neighborhood Healthcare offers a generous benefit plan that includes: Partially company paid Medical, Dental, and Vision Plans. Two plus weeks of vacation, Nine Holidays including two Floating Holidays of your choosing, Sick/Personal time, Volunteer Time Off (VTO), 403b Retirement plan (similar to a 401k), optional Health and Wellness events, and much more!
Pay range: $80,600.00 - $92,560.00 annually, depending on experience. (Exempt position)
#NHCN23