Social Worker (MSW)

Redwood Coast PACE with Humboldt Senior Resource Center is looking for a full-time Social Worker (MSW) to support our participants. Redwood Coast PACE — a Program of All-inclusive Care for the Elderly — is a comprehensive health plan for older adults who wish to remain living in their home and community. We provide medical, social, nutritional, rehabilitation, and support services for eligible adults. At Redwood Coast PACE, the goal is to help people stay as healthy and independent as possible. Because their health is monitored on a regular basis, many PACE participants report fewer health crises and better overall health.The schedule for this position is Monday through Friday, 8 am to 5 pm.JOB SUMMARY: Under the supervision of the Social Work Supervisor, the Social Worker (MSW) provides direct social work services to the participants of Redwood Coast PACE including participant assessments, case management, counseling, and referral.ESSENTIAL DUTIES AND RESONSIBILITIES:Provides comprehensive initial assessments, care planning, and on-going reassessments of participant care.Provides pre-enrollment assessments, safety visits, and when appropriate, may provide other assigned assessments in order to validate eligibility criteria to ensure complete documentation, particularly related to health and safety in the community. Provides this information to the Interdisciplinary Team (IDT) to confirm enrollment eligibility.Conducts reassessments to determine progress achieved and updates goals.In conjunction with the IDT, develops and implements a therapeutic Plan of Care with ongoing recommendations at least quarterly and when a participant’s condition changes. Presents and communicates the Plan of Care with the Interdisciplinary team, participants, family members, and/or caregivers as necessary.Ensures care coordination when appropriate within PACE, the family unit and/or community.Ensures that enrollment and disenrollment policies and procedures are followed. Assists the Social Work Supervisor and Enrollment Representative in clarifying enrollment and disenrollment information to potential participants, family members, caregivers, and/or other healthcare providers as necessary.Provides an Emergency Plan for each newly enrolled participant.Contributes to the success of the enrollment process which may include the introductory visit, home safety assessment, clinic visits, assessments, family meetings, and enrollment conferences. Ensures that PACE policies and procedures related to participant rights and responsibilities are consistently followed.Maintains current, accurate, and timely written progress notes and other documentation on the participant medical records.Provides participant and/or family with individualized counseling sessions and may develop and lead group sessions as required to ensure continuation of the Plan of Care.Makes recommendations to Primary Care Providers for assessment, treatment, ongoing treatment, or diagnosis of behavioral and/or mental health needs.Refers participants and families to appropriate community services and acts as a liaison and/or advocate with community organizations.Provides written and verbal information about Participant Rights and Responsibilities and the grievance and appeals processes to participants at enrollment, disenrollment (if appropriate), and annually. May be the initial point of contact for complaints, grievances, appeals, and/or interface with Redwood Coast PACE services to assure adherence to Participant Rights and Responsibilities.Works closely with participants and family members or caregivers during the disenrollment process, including developing a Referral Plan and assisting with referrals for primary care and community services.Effectively leads the Discharge Planning process, and in collaboration with IDT and outside providers, facilitates transfers from one level of care to another to help prevent re-hospitalization.Assists participants and their family or caregivers to file a grievance, appeal, and/or Incident Report as requested.Encourages effective relationships among employees to support the development and maintenance of a cohesive team. Consults with and advises other employees regarding the relationship of social, emotional, and cultural factors to health and medical care, and to the availability of social services in the community.Partners with Social Work Supervisor to ensure Corrective Action Plans are created, implemented, and evaluated to address employee and participant concerns.Participates in PACE program development from the Social Work perspective.Understands fiscal issues and is appropriately involved in meeting budget targets.Complies with safety policies and procedures, identifying and immediately reporting any potential or actual unsafe acts or conditions to the Social Work Supervisor. Takes necessary measures to ensure a safe environment for oneself, co-workers, contractors, participants, visitors, and others.Continually seeks better ways for delivering services and communication with participants.Promotes and demonstrates respect for participant rights including dignity, self-determination, access to care, confidentiality, and independence.Understands the importance of community involvement and participates as appropriate in activities that link PACE to the community.Effectively collaborates with employees and contractors to meet Redwood Coast PACE goals and further success.Complies with all policy and procedures.Demonstrates proficiency in delivering age-specific care.Consistently meets or exceeds PACE quality assessment and performance improvement targets.Participates in the process of teaching, training, and mentoring student interns and volunteers working within the program area.Acts in a manner consistent with agency values.Other duties as assigned.EDUCATION &/or EXPERIENCE:Master’s Degree from an accredited school of Social Work required.Two (2) years of social work experience preferred.Experience in the health care field preferred.Minimum of one (1) year of experience working with a frail or elderly population preferred.LICENSES OR CERTIFICATES:Current CPR and First Aid certification within six (6) months of hire.Valid California Driver’s License and personal auto liability insurance required. Must have a personal vehicle in good driving/operating condition and insured for State minimum liability requirements that can be used for the applicable job functions.Licensing by the California Board of Behavioral Sciences, as a licensed Clinical Social Worker, is preferred but not required.PRE-SCREENING REQUIREMENTS:Requires clearance of a DOJ and FBI criminal history background checkPre-employment physical and PPD skin test.Requires Motor Vehicle Report verification.COVID-19 and Influenza (flu) vaccines preferred.JOB SKILLS:Ability to work effectively in a team environment.Age-specific competency in working with the elderly. Working knowledge of community services for the elderly and their families.Knowledge of social work principles and practices, including case management and counseling techniques.Excellent interpersonal interactions that result in team building, successful negotiation, and conflict resolution.Demonstrates effective social interaction with co-workers, management, and community contacts.Exhibits the ability to complete duties within an agreed upon time frame and to adjust personal schedule if required.Adapts appropriately to change of priorities and workload.Maintains a consistent level of productivity.Demonstrates sound written and verbal communication skills to convey information effectively.Maintains a positive attitude and balance in relationships with others.Incorporates an understanding of detailed requirements in action plans and implementation.Strong basic computer skills (Microsoft Outlook, Word, Power Point, and Excel). Ability to navigate, use, and maintain database software programs. Basic knowledge of web-based applications such as timekeeping, training, and email programs.PHYSICAL REQUIREMENTS:Ability to sit at a desk and interact with a computer screen for extended periods of time.Hand and arm strength sufficient to operate a keyboard for several hours each day.Physical abilities sufficient to move between different staff work areas, communicate with staff and the public, operate a computer, produce reports, talk on the telephone, and travel to other agency worksites.The above statements are intended to describe the general nature of work performed. They are not to be considered an exhaustive list of all job tasks performed. The agency reserves the right to change job descriptions, work hours or work sites as required by the program.The Humboldt Senior Resource Center is a private, non-profit, multi-purpose senior center providing a continuum of social and health related services. The agency currently holds contracts with the California Department of Aging and Area 1 Agency on Aging.The Humboldt Senior Resource Center is an equal opportunity employer. We will not unlawfully discriminate against qualified applicants or employees with respect to any terms or conditions of employment based on race, color, national origin, ancestry, sex, sexual orientation, age, religion, physical or mental disability, medical condition, pregnancy, breastfeeding, gender identity, marital status, citizenship status, military or veteran status, genetic information, or other basis protected by applicable Federal or State law. #J-18808-Ljbffr Humboldt-Senior-Resource-Center-1