Social Worker Lead (SWMSWLD)

On Lok•Union City, CA

6d•Hybrid

About The Position

On Lok PACE is a non-profit organization dedicated to the care of elders through the Program of All-Inclusive Care for the Elderly (PACE). The PACE model focuses on serving seniors with chronic care needs and their families within their community. The Social Work Lead (SWL) provides direct case management services and acts as a subject matter expert, offering department leadership, mentorship, and consultation. The primary role is to assist participants and their families/caregivers with social, emotional, and practical issues to maintain independence. The SWL is an integral member of the Interdisciplinary (IDT) team, conducting assessments, coordinating care, developing treatment plans, and connecting participants with community resources.

Requirements

Graduate of an accredited college with a MSW degree.
Three years' experience in social work.
Minimum two years' experience in the geriatric field and/or with a frail population.
At least one year of leadership experience.
Experience or ability in working with a diverse population.
Experience working within the framework of an interdisciplinary team.
Good interpersonal skills including ability to work cooperatively on an interdisciplinary team.
Highly organized and has the ability to prioritize and work under extreme pressure.
Excellent written and verbal communication skills.
Flexible, creative problem solver.
Computer literate and basic knowledge of Microsoft Office.
Bilingual ability may be required for specific assignments.

Nice To Haves

Experience with electronic health record system (preferred).
Minimum two years case management experience in geriatric field (preferred).
Minimum two years health care related experience (preferred).
Five or more years' experience in social work (preferred).

Responsibilities

Provide case management to a panel of participants using independent judgment and discretion.
Conduct initial and routine psychosocial assessments to develop, implement, and update individualized care plans and interventions.
Partner with caregivers and support systems to develop care plans and deliver services.
Identify risks and psychosocial problems, and assess service needs of each participant.
Advocate, refer, coordinate, and follow up on participant needs in a timely fashion.
Provide individual counseling and facilitate family conferences.
Liaise with the community to meet participants' specific needs.
Act as the main liaison between participants, caregivers, the team, and the community.
Assess needs and complete discharge planning when a participant dis-enrolls from On Lok.
Facilitate participant and/or caregiver groups and participate in special events.
Work with relevant departments such as Health Plan and other community agencies.
Adhere to all ethical and legal standards of social work practices.
Comply with all On Lok policies & procedures, including safety and confidentiality requirements.
Fulfill all documentation requirements in a timely and accurate manner.
Actively participate in team meetings, advocate for participants and caregivers, and support team plans.
Incorporate the Healthcare Hospitality G.R.E.A.T. Practices for 5-Star service.
Act as the subject matter expert (SME) of the electronic health record for the social work department.
Assist in the review and update of department and IDT policies and procedures.
Assist in the orientation and training for new Social Workers and Social Work Aides.
Assist in overseeing competencies for social workers.
Assist in developing, maintaining, and facilitating relationships with other clinical disciplines and non-clinical staff.
Assist with developing the social work education program.
Serve as the primary point-person for social work issues at the appointed center.
Assist in providing support to Social Workers at the appointed center.
Assist in the continuous quality improvement of social work services and efficiency of systems.
Actively participate and contribute to the Social Work Leadership Council (SWLC) activities.
Assist with developing the social work continuing education program.
Contribute clinical and/or workflow process perspectives regarding participant care to the Program Manager.
Assist in coordinating student placements (interns), including training, oversight, and evaluations.
Actively participate as a change agent in On Lok's organizational vision and mission.