PACE Social Worker

Job Description

Primary Accountability

The Social Worker is responsible for the direct social work care management services to the participants of the FHCN PACE program. Provides social service support such as participant screening, case management, counseling, and referral.

Description of Primary Responsibilities:

1. Participate in the Interdisciplinary Team's initial assessments, care planning, and periodic re-assessments (minimally every 6 months) of the participant's case in accordance with industry and departmental standards. Assessments are to be completed prior to the scheduled team meetings.
2. Document participant changes appropriately in the medical record in accordance with industry and departmental standards.
3. Document participant changes appropriately in the medical records and communicate participant changes to IDT in a timely manner.
4. Participate as a member of the IDT. Attend staff meetings and take part in participant care planning.
5. Communicate effectively and openly with other Interdisciplinary Team members on participant status and needs.
6. Maintains current documentation records, including initial and periodic reassessments of program participants.
7. Coordinate 24-hour care delivery and provide individual and family counseling for participants.
8. Develop and lead group counseling and activities.
9. Refer participants and families to appropriate community agencies or facilities, act as a liaison with such organizations, and as an advocate for participants.
10. Encourage effective relationships among staff geared toward team building and maintenance of a cohesive team.
11. Consult with and advise staff members in regard to the relationship of social, emotional, and cultural factors to health and medical care, and to the availability of social services in the community.
12. Participate in program and policy development in regard to social work; demonstrate active participation in QI processes.
13. Perform home visits to private homes of FHCN PACE participants;
14. Participate as a member of the Interdisciplinary Team: attend staff meetings and take part in participant care planning.
15. Knowledgeable of Medicaid financial criteria including documentation to be completed.
16. Knowledge of participant liability and applicable share of cost.
17. Knowledge of applicable state requirements of Level of Care.
18. Interdisciplinary Team: Participate as an active and cooperative member of the Interdisciplinary Team. Attend staff meetings and take part in participant care planning.
19. Responsible for adhering to the Attendance and Absenteeism Policy, recognizing that regular attendance is considered an essential function of all FHCN positions. Absenteeism is not being at work or failing to attend a paid workshop, training, or event unless the absence is protected by law.
20. Ability to present to and work at any FHCN location, both at the beginning of a shift or during a shift, based on business need.
21. Performs other duties as assigned.

Description of Primary Attributes

Professional & Technical Knowledge:

Effective June 1, 2026, all individuals hired into the role must:

1. Possesses specific advanced knowledge and skills, including written and verbal communication skills, computational, computer, and technical skills, and mathematical knowledge, frequently acquired through one of the following:
   1. Completion of a Master's degree program with a recognized major with a minimum cumulative GPA of 2.5; or
   2. Successful attainment and maintenance of a valid, active professional license required for the role, issued by the appropriate governing or regulatory body.
2. Master's Degree in social work from an accredited college or university.
3. Either have one year of experience working with a frail or elderly population or, in the absence of such experience, receive appropriate training from the FHCN PACE on working with a frail or elderly population upon hiring. Minimum two years experience in a health-related area or equivalent experience.
4. Meet a standardized set of competencies for the specific position description established by FHCN PACE and approved by CMS before working independently.
5. Be medically cleared for communicable diseases and have all immunizations up to date before engaging in direct participant contact.
6. Completes competency profile prior to direct participant care.
7. Work effectively in a team environment.
8. Communicate effectively and have interpersonal and conflict-resolution skills.
9. Only act within the scope of his/her authority to practice.
10. Meet a standardized set of competencies for the specific position description established by FHCN PACE and approved by regulatory agencies before working independently.
11. Be medically cleared for communicable diseases and have all immunizations up to date before engaging in direct participant contact.
12. Pass a criminal background which will verify that the candidate is: not excluded from participation in Medicare and Medicaid programs; has not been convicted of criminal offenses related to their involvement in Medicaid, Medicare, other health insurance or health care programs, or social services programs under title XX of the Act; and have not been convicted of physical, sexual, drug or alcohol abuse.
13. Individual therapy (psycho-social) techniques for geriatric participants.
14. Basic computer skills and use of electronic mail.
15. Analytical thinking and problem-solving skills.

Technical Skills:

1. Ability to create highly complex documents in Microsoft Word, including linking multiple files and embedding objects linked to other documents.
2. Ability to use advanced functions of Microsoft Excel, such as creating and managing databases, including creating standardized reports, or linking multiple worksheets and workbooks.
3. Ability to develop sophisticated presentations in Microsoft PowerPoint, including the use of embedded objects, transitions, and other elements.

Licenses & Certifications:

1. Current Licensed Clinical Social Worker (LCSW) is preferred.
2. Valid CA driver's license and vehicle, or other approved means of transportation, and an acceptable driving record are required.
3. Currently certified in cardiopulmonary resuscitation (CPR), if CPR is not current, will be granted 30 days from the date of hire to schedule for the next available CPR certification class provided by FHCN.

Communications Skills:

1. Job duties require the compilation and analysis of information prepared in an effective written form, including correspondence, reports, articles, or other documentation.
2. Duties require preparation and execution of presentations to large groups.

Physical Demands and Work Environment:

The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform essential functions.

Physical demands: Employees may be required to conduct home visits to the private homes of FHCN PACE participants (frequent travel). Employees must be able to sit for extended periods of time. Employee


Work Environment: Employees must be able to work effectively within an interdisciplinary team model, interfacing and collaborating will also be active members of the interdisciplinary team at the FHCN PACE center, engaged with employees, participants, and staff. Employees are required to use their hands and fingers, especially for typing on the computer and using the mouse. Employees must be able to talk and listen, particularly for daily interactions with staff and elderly participants. Must be medically cleared for communicable diseases and have all immunizations up to date before engaging in direct participant contact.

There will be a wide range of clinical and social services disciplines who work together to manage the FHCN PACE members' care. The work setting is in an Adult Day Health Center and primary care clinic environment with moderate noise levels and controlled office temperatures.

Pay Scale:


Min Salary Rate: $79,543.00

Max Salary Rate: $119,314.00