POSITION SUMMARY: Under the direction of the Social Worker Director, the Social Worker is responsible for direct social work case management services to PACE participants. PRINCIPAL DUTIES AND RESPONSIBILITIES: The following represents most of the duties performed by the position but is not meant to be all-inclusive or prevent other duties from being assigned when necessary: · Participates as a member of the interdisciplinary team (IDT) and in initial, semi-annual, unscheduled, and annual assessments; attend morning updates and report changes in participants’ baseline status to appropriate staff on a daily basis. · Involved in the development and implementation of QI activities. · In conjunction with the IDT, may conduct the initial intake, meeting with family members and others. Coordinate ongoing family meetings, as needed. · Acts as a liaison between participant and internal/external service providers. · Obtains extensive psychosocial[KH1] history from participant and/or family member upon admission to program. · Provides individual and family counseling as needed or prescribed in the plan of care; develop and lead group counseling and support activities. · Provides crisis intervention and advocacy as required. · In conjunction with the IDT, coordinates discharge planning for participants returning home from hospital or nursing facility. · Maintains current, written case management records, including ongoing documentation of services provided, reassessment of changing needs and participant’s expressed wishes. · Demonstrates a thorough understanding of HIPAA/HITECH laws and the related policies and procedures within the agency. Attends and successfully completes mandatory HIPAA/HITECH training at least annually. · Assists with ongoing financial eligibility for participants, including recertification as needed. · Participates in participant-related conferences in the community as designated. · Attends and participates in all staff meetings, in-services, projects, and committees as assigned. · Adheres to and supports the center’s policies, practices, and procedures. · Maintains flexibility in schedule of hours worked. · Participates in special projects and performs additional duties as required or assigned.
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Job Type
Full-time
Career Level
Mid Level