Senior Services Social Worker I - $28.85 per hour - Las Vegas

Access To Healthcare Network•Paradise, NV

1d•Hybrid

About The Position

The Senior Services Social Worker I supports older adults and individuals with disabilities in accessing services, resources, and supports that promote independence, community integration and quality of life. This position is primarily assigned to Money Follows the Person (MFP) Program where it serves individuals transitioning from institutional settings, including nursing facilities and other long-term care environments, into community-based living arrangements. Working in partnership with healthcare providers, community organizations, and housing partners, this position provides person centered transition planning, care coordination, resource navigation and follow-up services to ensure participants achieve safe, successful, and sustainable community living. This position serves as a key member of the MFP team and is responsible for helping participants identify goals, access services and supports, overcome barriers to community reintegration, and maintain independence following discharge from institutional care.

Requirements

Bachelor's degree in social work, Human Services, Psychology, Gerontology, Public Health, or a related field required.
Minimum of two years of experience in case management, care coordination, discharge planning, social services, aging services, disability services, healthcare, behavioral health, or a related field.
Spanish – English Bilingual preferred.
Must obtain Medicare Assistance Program Level II Certification within 2 months of hire.
Valid Nevada Driver's License required with an acceptable five-year driving record that meets AHN insurance requirements.
Occasional use of personal vehicle for business related travel may be required, with reimbursement provided according to organizational policy.
Flexibility to accommodate department-determined work schedules, which may change based on operational needs.
Must pass a State of Nevada screening check and adhere to HIPAA regulations.

Nice To Haves

Experience working with older adults, individuals with disabilities, or persons requiring long-term services and supports preferred.

Responsibilities

Conduct comprehensive assessments to identify participant strengths, needs, preferences, and goals related to community living.
Develop and implement person-centered transition plans in collaboration with participants, family members, facility staff, and community partners.
Coordinate services necessary for community reintegration, including healthcare, behavioral health, transportation, nutrition, housing, and long-term support services.
Facilitate communication among providers and stakeholders to ensure seamless transitions and continuity of care.
Participate in interdisciplinary team meetings and case conferences as required.
Maintain regular contact with participants before, during, and after transition to community living.
Monitor participant progress and service delivery to ensure needs are being met.
Identify and address barriers that may impact successful transition outcomes.
Assist participants in obtaining benefits, services, and community resources.
Provide education regarding available supports, rights, choices, and self-advocacy.
Build and maintain relationships with nursing facilities, hospitals, housing agencies, social service organizations, and community providers.
Connect participants to appropriate community resources and services.
Collaborate with state and local partners to improve access to community-based services and supports.
Participate in outreach, education, and networking activities that promote MFP services and objectives.
Follow all MFP program requirements, policies, and procedures.
Maintain accurate, timely, and complete participant records in accordance with program, agency, and regulatory requirements.
Document assessments, service plans, referrals, participant contacts, and outcomes.
Track participant progress and required program data for reporting purposes.
Ensure compliance with all applicable confidentiality requirements, including HIPAA.
Provide case management services by phone, email, or in-person at approved locations.
Conduct home visits and offsite outreach as needed to meet consumer needs.
Participate in outreach, marketing, and public education activities, including community events.
Maintain working knowledge of AHN programs, systems, and required databases.
Communicate effectively with supervisors and internal departments.
Attend staff meetings and supervision sessions.
Adapt to changing priorities and perform other duties as assigned.