Social Worker-PACE (Murrieta)

Neighborhood Healthcare•Murrieta, CA

6d•$80,200 - $115,500•Onsite

About The Position

Community health is about more than just vaccines and checkups. It’s about giving people the resources they need to live their best lives. At Neighborhood, this is our vision. A community where everyone is healthy and happy. We’re with you every step of the way, with the care you need for each of life’s chapters. At Neighborhood, we are Better Together. Neighborhood Healthcare PACE is a managed medical plan built around surrounding participants with a team of physicians, nurses, social workers, therapists and care coordinators to help them maintain good health and a good quality of life. Our goal is to keep our seniors happy and healthy at home surrounded by their family and community. As a private, non-profit 501(C) (3) community health organization, we serve over 500k medical, dental, and behavioral health visits from more than 100,000 people annually. With two PACE centers located in Riverside County, our PACE program is positioned to serve over 650 senior participants. The Social Worker will manage a caseload of participants by providing a psychosocial perspective to the interdisciplinary evaluation, assessment, plan of care, ongoing services, and disenrollment processes of the PACE program at Neighborhood Healthcare. This role will collaborate with the interdisciplinary team to optimize the health status and quality of life of Neighborhood PACE participants. Additionally, this role will liaise between participants, members of participants’ support network, and the interdisciplinary team. Schedule: M-F 8am-5pm. This position is fully onsite.

Requirements

Master’s degree in social work required
One year of experience working with the elderly population required
Current Basic Life Support (BLS) certification required upon hire and must be maintained as a condition of employment. These courses must follow AHA guidelines- may be completed through approved online providers such as ProMed or other equivalent programs that meet recognized BLS standards.
In addition, current CPR and First Aid certification are required for all PACE employees in accordance with CMS and DHCS requirements. First Aid training will be provided at onboarding and must be renewed annually

Nice To Haves

One year of social work experience preferred
Experience working in a community-based setting or geriatric program preferred
Bilingual (English/Spanish) preferred
Excellent verbal and written communication skills, including superior composition, typing and proofreading skills
Ability to interpret a variety of instructions in written, oral, diagram, or schedule form
Knowledgeable about and experience with counseling theories and techniques
Knowledgeable about and experience with community resources for individuals and families
Ability to establish and maintain good interpersonal relationships
Ability to successfully manage multiple tasks simultaneously
Excellent planning and organizational ability
Ability to work as part of a team as well as independently
Ability to work with highly confidential information in a professional and ethical manner

Responsibilities

Works with the PACE Interdisciplinary Team (IDT) to conduct initial, semi-annual, unscheduled, and annual assessments
Provides participant health status updates to appropriate staff in daily meetings
Obtains extensive psychosocial history from participants and/or family members upon admission to program and intermittently at pre-enrollment
Coordinates, schedules, and facilitates family conferences in conjunction with the PACE IDT to address levels of care, medication/treatment non-compliance, out-of-home placement, complex diagnoses, behavioral concerns and contracts, conditions of involuntary disenrollment, and alternative program options
Develops and facilitates various group counseling topics designed to assist at-risk populations over the age of 55 with chronic health conditions
Provides individual caregiver and family support counseling, as needed
Coordinates with participants, family/caregivers, and primary care providers to complete advance life planning documents, assist with end-of-life planning, and provide educational resources
Conducts independent risk and safety assessments at skilled nursing facilities, residential care facilities for the elderly, assisted living facilities with/without memory care units, hospitals, and in-home, as needed
Screens and develops share of cost for out-of-home placements based on financial documentation from participants and family members
Creates and executes supportive housing forms with care facilities and family members,
Conducts intermittent and annual income reviews to update supportive housing forms and share of costs
Schedules, coordinates, and accompanies participants and family members with transportation and admission to higher level of care to promote safety and continuity of care in cases of high acuity
Implements hospice and palliative care services by providing referral documentation, coordination, education, and support to participants and families
Communicates with hospitals/skilled nursing facilities and utilizes external medical records systems to coordinate tailored discharge planning for participants
Assists with ongoing financial eligibility for participants, including Medi-Cal recertifications, as needed
Liaises effective connections and communications with other organizations in the eldercare field
Provides support and education to staff members in areas of social, emotional, and cultural factors in the participant population, including how these factors relate to health, medical care, and the availability of social services in the community
Schedules, coordinates, and conducts in-home visits and assessments independently and in conjunction with the PACE IDT, as needed
Provides redirection and support for participants with behavioral needs during PACE Day Center attendance, utilization of PACE transportation, and use of other PACE services
Refers participants and families to appropriate community agencies and facilities while acting as an advocate and liaison with such organizations
Conducts discharge planning to promote continuity of care in the event of disenrollment
Maintains federally compliant and timely documentation of institutionalizations, Adult Protection Service reports/follow-ups and consultations, community contacts, family conferences, assessments, and other case management notes in medical records
Attends required staff meetings/trainings and voluntary professional development courses