Social Worker - MSW

Job Description Join BoldAge PACE and Make a Difference! Why work with us? A People First Environment: We make what is important to those we serve important to us. Make an Impact: Enhance the quality of life for seniors. Professional Growth : Access to training and career development. Competitive Compensation Medical/Dental Generous Paid Time Off 401K with Match* Life Insurance Tuition Reimbursement Flexible Spending Account Employee Assistance Program BE PART OF OUR MISSION! Are you passionate about helping older adults live meaningful, independent lives at home with grace and dignity? BoldAge PACE is an all-inclusive program of care, personalized to meet the individual health and well-being needs of our participants. Our approach is simple: We listen to our participants and their caregivers to truly understand their needs and desires. Social Worker JOB SUMMARY: The Social Worker (MSW) provides direct social work and care management services to participants of the PACE program, offering comprehensive support to enhance their quality of life and ability to live independently in the community. Responsibilities include participant screening, case management, counseling, and referrals, as well as planning, organizing, and implementing social work services tailored to participants and their families. As a liaison between the interdisciplinary team, caregivers, and community agencies, the Social Worker ensures participant needs are effectively addressed, and services are coordinated seamlessly. This role is essential in promoting participant well-being, advocating for their needs, and advancing the mission and goals of the PACE program. ESSENTIAL DUTIES AND RESPONSIBILITIES: Participate in initial assessments, care planning, and periodic reassessments (at least every six months) of participant cases, ensuring assessments are completed prior to team meetings and adhere to departmental standards. Document participant changes and updates in the medical record accurately and in compliance with industry and departmental standards. Collaborate and communicate effectively with Interdisciplinary Team (IDT) members regarding participant status, needs, and care plans. Maintain up-to-date case management records, including periodic participant reassessments, and ensure comprehensive documentation. Coordinate 24-hour care delivery and provide individual and family counseling to support participants and caregivers. Develop and facilitate group counseling sessions and activities to address participant needs. Refer participants and families to appropriate community resources, acting as a liaison and advocate to ensure access to needed services. Foster effective relationships among team members, promoting team building and cohesion. Consult with staff on the impact of social, emotional, and cultural factors on participant health, and advise on available social services in the community. Participate in program and policy development for social work services and contribute to Quality Improvement (QI) processes. Conduct home visits to participants’ private residences to evaluate and support their needs. Actively participate in IDT meetings and contribute to care planning and team discussions. Perform additional duties and special projects as assigned. EXPERIENCE AND EDUCATION: Master’s degree in Social Work from an accredited school of social work accredited by the Council on Social Work Education. Member of the Academy of Certified Social Workers (ACSW) or other NASW-recognized certification preferred. Current License in the required state. Two (2) years of experience working on an interdisciplinary team in a hospital, nursing home, or community-based setting is preferable. 1 year of experience working with a frail or elderly population preferred. If this is not present, training will be provided upon hiring. PRE-EMPLOYMENT REQUIREMENTS: Must have reliable transportation, a valid driver's license, and the minimum state required liability auto insurance. Be medically cleared for communicable diseases and have all immunizations up to date before engaging in direct participant contact. Pass a comprehensive criminal background check that may include, but is not limited to, federal and state Medicare/Medicaid exclusion lists, criminal history, education verification, license verification, reference check, and drug screen. BoldAge PACE provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. *Paid Time Off Includes seven holidays * Match begins after one year of employment Full Time Monday- Friday 8am-4:30pm Full- Time