Social Worker | MSW

The PACE Social Worker is responsible for planning, organizing, and delivering social work services to participants and their families enrolled in the PACE program. Key responsibilities include conducting comprehensive psychosocial assessments, developing and implementing care plans in collaboration with an interdisciplinary team, providing individual and family counseling, facilitating access to community resources, and advocating for participant needs to support continued community living. The Social Worker also plays a critical role in care transitions and serves as a liaison among participants, caregivers, the interdisciplinary team, and external agencies.

Position Details

• Work Location: PACE Place, 5450 Ramona Blvd, Jacksonville, FL 32205
• Education Required: ** Masters of Science in Social Work (MSW) ** Candidate MUST have a minimum of an MSW for position interview.
• Days/Hours: Monday - Friday 8:00am -5:00pm
• Compensation: $56,000 - $60,000 annual, plus full benefits package including 23 days annual PTO
• Learn More: PACE Place

Job Responsibilities

• Conduct in-person psychosocial assessments for new and existing participants to identify cognitive, emotional, and support needs.
• Collaborate with the interdisciplinary team to develop and update participant care plans.
• Attend and actively participate in daily interdisciplinary team meetings and support the coordination of 24-hour care delivery.
• Provide education, counseling, and support to participants and caregivers on topics such as aging, dementia, grief, family dynamics, and disease processes.
• Facilitate the use of social services and assist with housing, financial support, advance care planning, and legal documents (e.g., MDPOA, DNR).
• Perform home, hospital, and facility visits as needed for assessment, support, and discharge planning.
• Coordinate transitions in care including temporary respite, long-term placement, or disenrollment.
• Maintain timely and accurate documentation in participant medical records.
• Advocate for participants with external agencies such as Adult Protective Services and Housing Authorities.
• Assist with grievances, appeals, and Medicaid eligibility processes.
• Ensure compliance with all regulatory and internal documentation, assessment, and service delivery requirements.
• Participate in continuing education and contribute to quality improvement efforts.

Desired Knowledge & Skills

• Deep understanding of psychosocial issues affecting frail, elderly, and chronically ill individuals.
• Strong assessment, counseling, and case management skills.
• Effective communication and interpersonal skills.
• Skilled in documentation and professional writing.
• Ability to work collaboratively with an interdisciplinary team.
• Proficient in Microsoft Office applications including Word, Excel, PowerPoint, and Outlook.

Experience Needed

• At least one year of experience working with a frail or elderly population (or must complete training upon hire).
• Preferably two years of experience on an interdisciplinary team in healthcare or community-based settings.
• Must meet standardized PACE competencies prior to working independently.

Education & Certifications

• Master's degree in Social Work from a Council on Social Work Education (CSWE)-accredited program.
• Current driver's license and auto insurance.
• CPR with First Aid or BLS certification required.

About PACE Place

PACE (Program of All-Inclusive Care for the Elderly) is a unique and innovative program that aims to keep frail and elderly adults in the community safe and independent at home for as long as possible. All PACE participants meet the nursing home level of care but can remain in the home they love with the support of the PACE interdisciplinary team (IDT).

The PACE Place opened its doors to the northeast Florida community in March of 2020 and serves select zip codes in Duval and Clay counties. At the PACE Place day center, participants can receive clinical services, therapy, meals, recreational activities, and personal care. In the home, PACE can provide skilled nursing and home health aide support, and some home-modification services deemed appropriate by the IDT to support participant safety. PACE also offers care coordination services via scheduling and transportation to/from outside specialist appointments.

The PACE Place is owned by Community Hospice and supported by Alivia Care, Inc. via shared services. The PACE Place falls along the continuum of care offered by Alivia Care, Inc. It embodies a unique model of all-encompassing care that allows frail elders in our community to age safely within their homes.