Health Caseworker

The Social Worker, MSW plans, organizes and implements social work services to participants and their caregivers in accordance with InnovAge policies and all applicable regulations. Conducts psychosocial assessments, participates in care planning and acts as a liaison between the participant and the interdisciplinary team. This role requires being on-site at the center and field-based work, including visits to participants' homes and other locations, to ensure continuity of care and support.
Assessment & Care Planning

Conducts initial psychosocial assessments (including SLUMS, PHQ-9, housing, food, financial security, MDPOA/decision-maker status).
Participates in IDT meetings, morning huddles, mini-teams, and PDPM meetings to ensure coordinated care.
Facilitates and documents participant care conferences, family meetings, and facility partnership meetings.
Participates in discharge planning and plan of care development, ensuring problems, interventions, and goals are well defined.
Supports participants transitioning between residences or care facilities, including arranging transportation and coordinating moves when no support system is available.
Functional Category: Case Management & Care Coordination

Serves as primary liaison between participant/family and the IDT, facilitating communication and resolution of care issues.
Coordinates respite SNF, ALF admissions, including transportation and discharge planning.
Documents housing encounters in EPIC
Collaborate with comfort care team for end-of-life activities
Collaborates with RN Case Management on hospitalizations, and provides psychosocial input
May serve as back-up to RNCM.
Reviews participant/family concerns with Ombudsman and escalates facility quality concerns; maintains admission holds on facilities with care issues and manages urgent rehousing when contracts terminate.
Provides counseling and psychosocial support in coordination with behavioral health for participants and caregivers as indicated
Completes comfort care assessments and provides guidance on transitions to end-of-life services.
Advocates for participants living in unsafe housing conditions
Provides notification and explanation of participant rights regarding Level of Care (LOC) denials or disenrollment declines.
Maintains accurate and timely documentation in Epic, EireneRx, and other systems (demographic updates, address/phone changes, participant chart updates).
Complete PASSR screenings, supportive housing forms and other like documents as mandated by federal and state agencies within regulatory timelines.
Partners with Eligibility Financial Determination teams to educate participants/families on required information/documentation needed to maintain and restore Medicaid eligibility
Ensures all participant care coordination complies with CMS, HCPF, and InnovAge policy requirements.
Participates in IDT and department meetings, cross-site collaboratives, trainings, and annual competencies.
Provides community education and participates in external support groups, inter-agency coordination, and partnership meetings with RCFEs as indicated
Coordinates with facilities on participant needs.
Travel Requirements
Travel

Travel may be required
Overnight travel may include local or out of state
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions
Master's degree from a school of social work accredited by the Council on Social Work Education

Licensure, Certification, Registration or Designation

Require personal transportation, current state issued driver's license, good driving record and auto insurance as required by law.
CPR/BLS and First Aid required in California only.
Work Experience and Qualifications

One year experience in a health care setting
Experience conducting psychosocial assessments, care planning and case management skills required.
Requires personal transportation, current state issued driver's license, good driving record and auto insurance as required by law.
Licensed Master Social Worker (LMSW) or Licensed Clinical Social Worker (LCSW)
Work Experience and Qualifications

~ Three years or more of social work experience