Master Social Worker

JOB SUMMARY: Assesses the psycho-social needs, provides of participants and advises the interdisciplinary team and his/her colleagues on the development and implementation of participant care plans. Provides social services support, case management, counseling and referrals to external agencies.

JOB RESPONSIBILITIES:

• Serves on the PACE interdisciplinary team (IDT).
• Performs assessments, scheduled reassessments and unscheduled reassessments of participant's history, personal and family circumstances, home environment, psycho-social status and cognition.
• Collaborates with other members of the IDT to develop participant plans of care.
• Refers participants to community agencies or facilities, acting as a liaison and advocating for participants to obtain services for which they are eligible.
• Communicates changes in participant status to interdisciplinary team members and notes changes in the plans of care.
• Helps participants cope with physical, social, emotional and psychological problems or disabilities.
• Helps participants understand and navigate Medical eligibility issues, tracking eligibility renewals and assisting with this process.
• Helps participants apply for social security disability and Medicare coverage as needed.
• Helps participants find better or alternative places to live, when appropriate.
• Helps participants maintain basic social supports so they remain safe, warm, and dry.
• Advises colleagues about ways to meet participants' social service needs.
• Develops and leads group sessions for cognitive stimulation and emotional health.
• Assists the clinical team with discharge planning and transitions of care, when necessary.
• Assists in the management of homebound participants and those at risk for caregiver stress through regular visits and telephone contact.
• Participates in family conferences, team meetings, committees and work groups as required.
• Participates in policy development and revision for the social work component of the program.
• Participates in the coordination ofa 24-hour care delivery system.
• Participates in the Quality Improvement program
• Completes all documentation in the medical record as required.
• Acts within the scope of his or her professional license.
• Assists MEOC with the completion and updating of the annual Uniform Assessment Instruments (UAI) on each participant, when possible.
• Other duties as assigned.

ESSENTIAL FUNCTIONS:

• Oral and written communication skills
• Interpersonal skills
• Computer skills
• Organizational skills
• Problem solving and conflict resolution skills
• Record keeping and reporting skills

SUPERVISORY RESPONSIBILITIES: None

QUALIFICATIONS:

Master's Degree from an accredited School of Social Work.

One or more years experience with a geriatric population.

Valid driver's license and reliable transportation.


Individual therapy, analytical thinking and problem solving skills.

Must work well as part of a team.

Medically cleared for communicable diseases with up-to-date immunizations before participant contact.

Criminal history records check at hire.

Drug screen at hire.

WORK SCHEDULE: Full Time. PACE Center operating hours are 8:30 a.m. to 4:30 p.m. Monday through Friday with occasional need for after-hours/weekend support.