SOCIAL WORKER

JOB PURPOSE Under the direction of the Social Work Manager, the Social Worker will provide social work services including: advocating, assessing, assisting, collaborating, educating, evaluating, implementing and planning for participants in various aspects of the participant's life including but not limited to psychological, psychosocial, financial, environmental, and interpersonal matters. Social work engagement takes place in various settings including but not limited to the participant's home, PACE site, community settings (hospital, SNF, ALF, etc.). The Social Worker will serve as a conduit among the participant/authorized representative, the Interdisciplinary Care Team and other community agencies (hospital, SNF, ALF, APS etc.) to ensure the highest level of satisfaction throughout the PACE lifecycle. The Social Worker will provide support to the PACE participant, including but not limited to concrete services, adjustment to illness/disability/treatment, crisis intervention, and end of life care. The Social Worker will assess and evaluate psychosocial functioning; conduct mental status assessments; participate in discharge planning; and enlist collateral community agencies’ services as applicable. JOB RESPONSIBILITIES Provide ongoing social work services to participants and their authorized representatives to help them understand and follow care delivery recommendations, and to assist them with personal and environmental challenges that predispose toward illness or interfere with obtaining maximum benefit from the PACE program. Educate participants and their authorized representatives in understanding and using community, health and public services and benefits that help them remain safely in the community (SNAP, SC/DRIE, Medicaid, Medicare, housing, etc.) and assist with making referrals, coordinating services and completing related documents as needed. Ensure timely and appropriate communication and coordination of care during/post hospitalization, or other inpatient stay, to ensure that a participant's wishes regarding his/her care are followed during that admission; report all communication with facilities, hospital/STR, to the IDT and document it. Provide social work consultation to participants and authorized representatives as indicated. Provide education on treatment options, including palliative and end of life care, and help coordinate services. Arrange bereavement assistance, supportive counseling, or other behavioral health services as needed. Provide caregiver support as needed. Complete biopsychosocial assessments (semi-annual, quarterly revisit, PRN, SOC, SCIC, SDR), cognitive/emotional status assessments (i.e. PHQ9, SPMSQ) and other assessments as applicable. Complete HCP documents and facilitate the completion of advance directives, such as DNR/DNI/DNH/MOLST documents. Assure participant-focused Care Plan psychosocial goals and interventions are applied. Utilize EMR for completion of assessments and other systems as needed. Ensure documentation is completed timely (within 48 hours) and accurately. Organize and manage workload to ensure provision of appropriate and maximized social services to participants and authorized representatives. Use case management and clinical skills to help participants and families address and resolve social, financial, and psychological problems related to the participant's health. Ensure timely and appropriate coordination and follow-through of care and services. Responsible for integrating best practices into the participant’s total care by collaborating with other professional personnel within CenterLight Healthcare, in acute care institutions, skilled nursing facilities, and other community agencies. Facilitate psycho-educational presentations for participants in the day health centers. Attend and actively participate in IDT and care plan meetings. Identify, document as part of the care plan and present social work-related concerns and/or issues and appropriate social work interventions and recommendations. Ensure social work interventions are applied and participant-centered goals are met. Participate in appropriate continuing education and professional training programs sponsored internally by CenterLight Healthcare and/or applicable outside agencies. Participate in staff enhancement through professional knowledge by attending approved seminars/workshops relevant to the field of Social Work. Participate in peer supervision conferences and individual conferences with the Social Work Manager/designee. Represent the Social Work department and CenterLight Healthcare at appropriate meetings and conferences in the community. Only act within the scope of the individual’s authority to practice. Meet a standardized set of competencies for the specific position description established by the PACE organization before working independently. Act as a member of the IDT. Perform all other duties as assigned by supervisor. QUALIFICATIONS Education: M.S.W. from an accredited college or university. Experience: One (1) year experience in a health care setting; minimum of one (1) year of experience working with a frail or elderly population. If less than one (1) year of experience but all other requirements are met, appropriate training from the PACE organization will be provided upon hiring. Experience in home care and/or field work is preferred. Regular access to a car for field visits is preferred but not required. Language: Chinese Bilingual (Mandarin, Cantonese, or Fuzhounese) preferred. License: LMSW or LCSW required; must have an active NY State Social Work license. Additional Requirements Be legally authorized to practice in the State in which the healthcare professional will perform the function. Be medically cleared for communicable diseases and have all immunizations up-to-date before engaging in direct participant contact. Physical requirements include: Standing up to 6 hours a day. Sitting/Stationary positions for up to 6-8 hours a day. Lifting/Push/Pull up to 50 pounds using OSHA guidelines. Bending/Squatting to care for patients and use medical supplies. Stairs/Steps/Walking/Climbing safely and walking between sites/locations throughout the day. Agility/Fine Motor Skills to operate equipment, devices, instruments, and tools. Sight/Visual Requirements to assess patients, read orders, write documentation accurately. Audio Hearing and Motor Skills to listen attentively, document information, and speak clearly. Cognitive Ability to demonstrate good decision-making, reasoning, and analysis. We are an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, height, weight, or genetic information. We are committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities. Salary Range (Min-Max): $85,280.00 - $102,960.00 CenterLight Healthcare PACE, a Program of All-Inclusive Care for the Elderly, serves adults 55+ throughout New York City, Westchester, Nassau, and Western Suffolk Counties. Designed for those with Medicare and/or Medicaid, the program empowers older adults to continue to live independently at home and in their communities. CenterLight’s PACE program is one of the largest nonprofit PACE programs in the country and operates 11 PACE centers and one Alternative Care Setting (ACS) where participants can receive on-site socialization, social and personal care services, therapeutic recreation, meals, and transportation. Schedule: 9:00AM – 5:00PM | Monday - Friday; Weekly Hours: 35. #J-18808-Ljbffr