Social Worker MSW PACE - FT - Day - LIFE Bordentown NJ

Capital Health (US)•Life, TN

4d•$64,626 - $84,448

About The Position

This position involves home visits to participants in the LIFE program. The social worker participates in the interdisciplinary team (IDT), supports coordinated 24-hour care delivery, assesses participants’ needs, and helps develop and implement comprehensive plans of care. The role provides counseling, education, advocacy, crisis intervention, and case management for participants and their families, while coordinating services with internal teams and community agencies. The social worker maintains case management records, conducts home visits to assess living environments and support systems, supports ongoing financial eligibility and recertification, and coordinates transitions to and from hospitals, nursing facilities, hospice, and other providers. The position also contributes to quality improvement activities, assists with grievances and appeals and advance-care directives, and provides guidance to team members on relevant participant and family concerns. The role requires home visits and may require work at another location or remotely as part of disaster recovery and business continuity plans.

Requirements

Master’s degree in social work.
Two years of social work experience.
One year of experience working with frail or elderly populations.
First aid certification or training required.
AHA BLS.
Driver’s license.

Nice To Haves

Current social work license in the state of the PACE organization is preferred.

Responsibilities

Promote collaborative relationships across Capital Health and contribute to a team environment, consensus building, and conflict resolution.
Maintain the department budget, order equipment and supplies as needed, identify financial vulnerabilities, and recommend cost reductions.
Follow applicable laws, regulations, ethical standards, policies, and procedures; understand and follow disaster recovery, crisis management, and business continuity plans.
Attend required training, in-service training, and educational classes.
Participate in the interdisciplinary team, communicate participant changes, and collaborate on care planning and coordination for 24-hour care delivery.
Perform initial, semi-annual, unscheduled, and annual participant assessments.
Coordinate with the interdisciplinary team to develop a comprehensive plan of care for each participant.
Participate in the development and implementation of QAPI activities.
Conduct initial intake meetings with family members and others and coordinate ongoing family meetings as needed.
Provide individual and family counseling as needed or prescribed in the plan of care, and develop and lead group counseling and support activities.
Provide participants and families with ongoing support, counseling, and education about aging, dementia, grief and loss, end of life, disease processes, family dynamics, changing roles, the PACE model, and PACE health services.
Maintain current written case management records, document services, reassess changing needs and participant wishes, and make periodic or as-needed home visits to assess living environments and support systems.
Assist with participants’ ongoing financial eligibility and recertification.
Provide training, supervision, oversight, and evaluation to case managers and case management services for participants and families.
Liaise between participants and agencies such as the Department of Aging, Social Security Administration, and Medicaid.
Act as a resource for team members and day center staff on topics including dementia, difficult behaviors, and difficult personalities.
Assist participants and caregivers with grievances and appeals; communicate personal-care needs, including clothing and durable medical equipment needs during hospital or short-term rehabilitation stays, and share relevant information with the interdisciplinary team.
Coordinate discharge planning for participants returning home from a hospital or nursing facility.
Provide crisis intervention and advocacy; offer emotional support, grief work, and education; make funeral and financial planning referrals when hospice care is appropriate; facilitate hospice or nursing home placement; and refer participants to community resources such as Adult Protective Services.
Assist participants and caregivers with Medical Durable Power of Attorney proxy and Do Not Resuscitate directives as needed.
Coordinate transitional care, including reinstatement of conventional Medicare and Medicaid benefits, transitions to other providers, referrals, and transfer of medical records when participants leave the PACE program.
Perform other duties as assigned.