PACE Master's Level Social Worker

Valir Health • Shawnee, OK

12d

About The Position

The Master's Level Social Worker serves as a primary source for coordinating transitions of care and participants’ mental and psychosocial care. The role counsels participants on financial and advance-care-planning options, including advance directives and DNR orders, advocates for participants, and ensures their wishes are enacted.

Valir PACE provides integrated medical and social services to seniors. The social worker works with participants, families, the PACE interdisciplinary team, external care providers, and community resources to coordinate appropriate care and support.

Responsibilities

• Serve as the primary point of contact for transitions of care.
• Arrange beds for appropriate levels of care, including acute, post-acute, and hospice care, and coordinate necessary team members and services such as the PACE interdisciplinary team, external care providers, pharmacy, and transportation.
• Find and obtain access to community resources for participants and families.
• Organize caregiver and other appropriate support groups for participants.
• Identify resources to meet each participant’s psychosocial needs.
• Provide case management services for patients.
• Assist participants and families with DNR orders and advance directives, ensuring advance directives are congruent with the participant’s disease process.
• Support participants in developing a clearly defined end-of-life plan that is communicated to family and the care team and reflects the participant’s wishes.
• Perform annual, bi-annual, and status-change assessments as required by federal and state regulations.
• Conduct routine mental health assessments, including assessments for depression, anxiety, and caregiver burnout, and make appropriate referrals for mental health services and caregiver support.
• Provide and recommend appropriate group counseling to support participants’ mental health hygiene and coping skills.
• Facilitate care-planning meetings, family meetings, and meetings with other care teams, such as nursing homes.
• Assist with escorting participants to appointments when needed to advocate for them.
• Perform other duties and responsibilities as assigned.

Benefits

• Competitive pay
• Retention and referral bonuses
• Medical, dental, and vision insurance
• Paid day off for birthday
• 401(k) company match on day one
• Company-paid life insurance
• Generous paid time off
• Career development opportunities
• Employee recognition

What This Job Offers

• Job Type: Full-time
• Education Level: No Education Listed