Licensed Social Worker - LBSW

Bluestem Communities Management•McPherson, KS

About The Position

Bluestem PACE is seeking a full-time Licensed Bachelor Social Worker (LBSW). The role provides a psychosocial perspective across PACE interdisciplinary evaluations, assessments, care plans, ongoing services, and disenrollment processes. Interventions include participant and family contacts, education and counseling, resource mobilization, behavioral health support, case management, advocacy, and discharge planning. The social worker applies knowledge of social systems and individual behavior to support participants and families, collaborating with the Interdisciplinary Team to optimize participants’ health status and quality of life. The social worker supports participants’ community stability and independence through care coordination, counseling, housing support, referrals, home visits, advocacy, and assistance with benefits and advance care directives. The position also documents services in participants’ medical records, supports transitions from PACE when needed, participates in quality improvement and organizational activities, and maintains professional affiliations, certifications, and continuing education. The role is part of a rotating on-call pool and may require responding outside regular business hours.

Requirements

Must be at least 18 years of age.
Working knowledge of Microsoft Office Suite.
Bachelor’s degree in social work from an accredited school of social work.
Active LBSW license in the state of Kansas.
Current driver’s license and proof of auto insurance.

Nice To Haves

Two years of experience working on an interdisciplinary team in a hospital, nursing home, or community-based setting.

Responsibilities

Attend and participate in daily Interdisciplinary Team meetings, communicate participant changes, and collaborate on care planning and coordination for 24-hour care delivery.
Serve as a liaison among participants, caregivers, community agencies, the Interdisciplinary Team, the day center, and other PACE staff.
Provide ongoing support, counseling, and education to participants and families on aging, dementia, grief and loss, end of life, disease processes, family dynamics, changing roles, and PACE services.
Help maintain participant housing through interventions with participants, caregivers, and housing providers; refer participants to subsidized housing and assisted living, and assist with applications, records, interviews, and tours when needed.
Help participants function at the most independent community level possible.
Present requests to the Interdisciplinary Team and coordinate admissions and discharges to contracted facilities for respite and permanent placement.
Conduct quarterly or as-needed home visits to assess living environments and support systems.
Facilitate meetings with participants, families, caregivers, and community agencies to clarify or resolve issues, including care plans, and mediate discussions.
Provide end-of-life emotional support, grief counseling, education, and referrals for funeral or financial planning; facilitate end-of-life or nursing-home placement as needed.
Refer participants to community resources such as Adult Protective Services, Housing Authority, and public utility companies, and advocate for participants with those entities.
Assist participants and caregivers with Medical Durable Power of Attorney, Proxy, and Do Not Resuscitate directives.
Attend and participate in organizational meetings, in-services, and community agency meetings related to participant care or daily operations.
Serve as a resource to team members and day-center staff on topics such as dementia, difficult behaviors, and difficult personalities.
Document services and significant events in participant medical records in accordance with PACE requirements.
Assist participants with Social Security Income and Social Security Disability Insurance applications as needed.
Assist participants and caregivers with grievances and appeals.
Help participants and families maintain resources within Medicaid eligibility guidelines and assist with annual Medicaid applications when needed.
Coordinate insurance and referrals for community- or facility-based services for participants disenrolling from PACE, as desired by the participant.
If Bluestem PACE terminates, coordinate transitional care, support reinstatement in conventional Medicare and Medicaid benefits, arrange transitions and referrals to other providers, and help transfer medical records with participant approval.
Practice only within the scope of authority to practice.
Participate in and support Quality Improvement initiatives.
Maintain professional affiliations, required certifications, and continuing education requirements.
Meet position-specific competencies before assuming participant care.
Serve in a rotating on-call pool and respond to calls and provide support outside regular business hours as needed.