Social Worker, MSW - Evergreen

InnovAge•San Bernardino, CA

8h•Onsite

About The Position

The Social Worker, MSW plans, organizes and implements social work services to participants and their caregivers in accordance with InnovAge policies and all applicable regulations. Conducts psychosocial assessments, participates in care planning and acts as a liaison between the participant and the interdisciplinary team. InnovAge is dedicated to empowering seniors to live independently, allowing them to age in their own homes and communities safely. InnovAge offers an alternative to nursing homes through its Program of All-inclusive Care for the Elderly (PACE), which provides enrolled seniors with customized healthcare and social support at PACE Adult Day Health Centers. These centers are staffed by medical professionals who are committed to creating personalized care plans for each participant. At InnovAge, our team members are our greatest asset and have a significant impact on the lives of our participants every day. When you join InnovAge, you'll work alongside talented, respectful, and passionate colleagues within a patient-centered care model.

Requirements

Master’s degree from a school of social work accredited by the Council on Social Work Education
Require personal transportation, current state issued driver’s license, good driving record and auto insurance as required by law.
CPR/BLS and First Aid required in California only.
Licensed Master Social Worker (LMSW) or Licensed Clinical Social Worker (LCSW) from The New Mexico Board of Social Work-LMSW License (for New Mexico applicants).
One year experience in a health care setting
Experience conducting psychosocial assessments, care planning and case management skills required.
A minimum of one year experience working with the frail or elderly.

Nice To Haves

Three years or more of social work experience

Responsibilities

Conducts initial psychosocial assessments (including SLUMS, PHQ-9, housing, food, financial security, MDPOA/decision-maker status).
Completes in-person reassessments at least every six months or as required.
Performs in-home visits as required by regulations or as indicated.
Participates in IDT meetings, morning huddles, mini-teams, and PDPM meetings to ensure coordinated care.
Facilitates and documents participant care conferences, family meetings, and facility partnership meetings.
Participates in discharge planning and plan of care development, ensuring problems, interventions, and goals are well defined.
Supports participants transitioning between residences or care facilities, including arranging transportation and coordinating moves when no support system is available.
Serves as primary liaison between participant/family and the IDT, facilitating communication and resolution of care issues.
Coordinates respite SNF, ALF admissions, including transportation and discharge planning.
Documents housing encounters in EPIC.
Collaborate with comfort care team for end-of-life activities.
Assists participant’s family with end-of-life coordination.
Collaborates with RN Case Management on hospitalizations, and provides psychosocial input.
May serve as back-up to RNCM.
Reviews participant/family concerns with Ombudsman and escalates facility quality concerns; maintains admission holds on facilities with care issues and manages urgent rehousing when contracts terminate.
Coordinates guardianship process for participants lacking decision-making capacity without a surrogate.
Obtains SNF/ALF updates for IDT, manages respite scheduling, and ensures placement transitions are supported.
Provides options counseling when appropriate.
Assists participants who are disenrolling with timely referrals to external services and completion of disenrollment paperwork.
Provides counseling and psychosocial support in coordination with behavioral health for participants and caregivers as indicated.
Completes comfort care assessments and provides guidance on transitions to end-of-life services.
Advocates for participants living in unsafe housing conditions.
Contributed to RCAs development, incident reporting, and follow-up for abuse, neglect, exploitation, and elopements.
Assists participants and caregivers with grievances and appeals, explaining rights and processes.
Provides notification and explanation of participant rights regarding Level of Care (LOC) denials or disenrollment declines.
Maintains accurate and timely documentation in Epic, EireneRx, and other systems (demographic updates, address/phone changes, participant chart updates).
Complete PASSR screenings, supportive housing forms and other like documents as mandated by federal and state agencies within regulatory timelines.
Supports Medicaid eligibility recertification processes.
Partners with Eligibility Financial Determination teams to educate participants/families on required information/documentation needed to maintain and restore Medicaid eligibility.
Accurate and timely reporting of disenrollments in required systems.
Escalates to Center Director service recovery is needed for a participant concern or disenrollment.
Ensures all participant care coordination complies with CMS, HCPF, and InnovAge policy requirements.
Participates in IDT and department meetings, cross-site collaboratives, trainings, and annual competencies.
Provides community education and participates in external support groups, inter-agency coordination, and partnership meetings with RCFEs as indicated.
Coordinates with facilities on participant needs.
Provides caseload coverage support as assigned for MSW PTO, open FTEs, and general team needs.
Performs other duties as assigned.