PACE Social Work Assistant

Family Health Centers of San Diego•San Diego, CA

10h

About The Position

Under the supervision of the Social Worker and PACE leadership, the PACE Social Work Assistant provides support services to help participants and caregivers navigate community resources, social service programs, and care coordination needs. The role assists with case management activities, documentation, participant follow-up, and service coordination to support participants in remaining safely in the community. The position works with participants, families, caregivers, community agencies, health care facilities, and the interdisciplinary team. It supports care transitions, participant engagement, resource access, and continuity of care, while maintaining documentation and confidentiality in accordance with organizational and regulatory requirements. Travel between sites and other locations is required.

Requirements

Current American Heart Association healthcare provider CPR (BLS), Advanced Cardiac Life Support, Advanced Trauma Life Support, or Advanced Resuscitation Training is required.
Travel between sites and other locations is required.
Must have a car, a valid California driver’s license, and proof of minimum car insurance levels required under California law; an acceptable driving record is also required.
Ability to establish and maintain effective working relationships with participants, families, caregivers, community agencies, and interdisciplinary team members.
Excellent interpersonal, customer service, and communication skills.
Ability to organize multiple tasks and meet deadlines in a fast-paced environment.
Ability to maintain participant confidentiality and exercise sound judgment.
Demonstrated ability to work effectively with culturally diverse populations.
Strong problem-solving, organizational, and follow-up skills.
Basic computer literacy, including electronic health records, Microsoft Office applications, email systems, and documentation systems.

Nice To Haves

Bachelor’s degree in social work or a related field.
At least 1 year of experience in case management, care coordination, social services, community outreach, healthcare, behavioral health, senior services, or a related field.
Experience working with frail elders, older adults, individuals with disabilities, or vulnerable populations.
Knowledge of community resources, health care systems, and social service programs within San Diego County.
Bilingual English/Spanish.

Responsibilities

Assist participants with applications and access to community resources and social service programs, including Medi-Cal, CalFresh, housing resources, transportation services, financial assistance programs, and other supportive services.
Assist Social Workers with case management activities and participant and caregiver follow-up.
Serve as a liaison between participants, families, caregivers, community agencies, hospitals, skilled nursing facilities, assisted living facilities, and the interdisciplinary team.
Support transitions of care, including hospital and skilled nursing facility admissions and discharges, and community placements.
Assist with scheduling and coordinating family meetings, care conferences, and participant-related meetings.
Provide telephone support and participant follow-up as directed by the Social Worker.
Conduct home and community visits as assigned and under the direction of the Social Worker.
Assist participants with forms, applications, benefit renewals, and document management.
Coordinate referrals to community agencies and supportive services.
Maintain current case management records and documentation in accordance with organizational standards and regulatory requirements.
Assist with collecting and organizing participant information for interdisciplinary care planning.
Support participant enrollment, disenrollment, transfers, and continuity-of-care processes.
Communicate participant concerns, psychosocial needs, and significant changes to the Social Worker and interdisciplinary team in a timely manner.
Participate in interdisciplinary team meetings, care planning discussions, and departmental meetings as assigned.
Assist with participant engagement activities, support groups, educational programs, recreational activities, and community outings.
Maintain confidentiality and comply with HIPAA, CMS, DHCS, and organizational requirements.
Promote excellent customer service and positive participant experiences consistent with organizational values and AIDET principles.
Perform other duties as assigned.