PACE Social Worker, MSW (Vista, CA)

San Ysidro Health•Vista, CA

About The Position

The PACE Social Worker provides direct social work case management services to participants in the San Diego PACE program, including screening, case management, counseling, and referrals. The role follows PACE policies and procedures, applicable laws, and licensing requirements. The Social Worker participates in participant assessments and care planning, coordinates care and community services, maintains case records, and serves as an advocate and liaison for participants and their families. The position also supports interdisciplinary teamwork, contributes to social work program and policy development, and performs related duties as assigned.

Requirements

Master’s degree from an accredited School of Social Work.
Valid California driver’s license and access to an insured vehicle.
Skills in counseling theory and techniques.
Organization and project management skills.
Ability to establish and maintain good interpersonal relationships.
Ability to work independently and meet deadlines.
Analytical thinking and problem-solving abilities.
Practice only within the scope of authorized practice.

Responsibilities

Participate in the Interdisciplinary Team’s initial assessments, care planning, and periodic participant reassessments at least every six months; complete assessments before scheduled team meetings.
Communicate participant changes to team members.
Maintain current written case management records, including periodic reassessments.
Provide in-home assessments and complete social service assessments for PACE participants.
Coordinate 24-hour care delivery.
Provide individual and family counseling, and develop and lead group counseling and activities.
Refer participants and families to appropriate community agencies or facilities, act as a liaison with those organizations, and advocate for participants.
Encourage effective staff relationships that support team building and a cohesive team.
Consult with and advise staff about how social, emotional, and cultural factors relate to health and medical care, and about available community social services.
Participate in program and policy development for the Social Work component.
Document participant changes appropriately in the medical record.
Actively participate in the Interdisciplinary Team, attend staff meetings, and take part in participant care planning.
Maintain working knowledge of facility service areas, including transportation, community characteristics, and geography.
Maintain networking liaisons with organizations in the eldercare field.
As requested, represent the agency in contacts with human service, health care, and community organizations and individuals.
Support professional growth through educational programs, current literature, in-service meetings, and workshops.
Adhere to and model SYHC’s core values and behaviors of Excellence, Empowerment, Integrity, and Respect.
Follow SYHC and PACE attendance and punctuality policies and practices.
Assist participants with Adult Meal Benefit forms upon enrollment and annually.
Perform other related duties as assigned or requested.
Work only within the scope of authority to practice.