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

Capital Health (US)•Life, TN

6d•$64,626 - $84,448•Onsite

About The Position

Capital Health is seeking a full-time Social Worker with an MSW to join their PACE program. This role is responsible for providing comprehensive social work services to participants, including assessments, care planning, counseling, and coordination with the interdisciplinary team and external agencies. The Social Worker will play a key role in ensuring the well-being and support of elderly and frail individuals within the PACE model of care.

Requirements

Master's degree in social work.
Two years of social work experience.
One year of experience working with the frail or elderly population.
First aid required.
Current license in social work within the state of PACE Organization preferred.
AHA BLS
Drivers License

Nice To Haves

Current license in social work within the state of PACE Organization

Responsibilities

Executes assignments in a culture that is shared and collaborative across all divisions within Capital Health.
Promotes and maintains collaborative relationships with managers, peers, direct reports, and customers by effectively fostering a team environment, building consensus, and resolving conflicts.
Maintains department budget, places orders for equipment and supplies as necessary.
Identifies financial vulnerabilities and makes cost reduction recommendations as needed.
Maintains a working knowledge of applicable Federal, State, and local laws and regulations, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior.
Knows proper disaster recovery protocol, crisis management, and business continuity plans, and acts within role that is developed within the business continuity plan.
Works at another location, remotely from home, and maintains constant contact with key personnel as required.
Attends and participates in scheduled training, in-service training, mandatory annual in-service training, and educational classes as required and needed.
Participates as a member of the interdisciplinary team (IDT).
Communicates participant changes, and collaborates on care planning decisions and coordination for 24-hour care delivery.
Performs initial, semi-annual, unscheduled, and annual assessments of participants.
Coordinates with IDT to develop comprehensive plan of care for each participant.
Participates in the development and implementation of QAPI activities.
Conducts initial intake meeting with family members and others, while coordinating ongoing family meetings as needed.
Provides individual and family counseling as needed or prescribed in the plan of care and develops and leads group counseling and support activities.
Provides ongoing support, counsel, and education to participants and family regarding a variety of issues, including the aging process, dementia, grief and loss, end of life, disease processes, difficult family dynamics and changing roles, PACE model, and PACE health services.
Maintains current, written case management records, including ongoing documentation of services provided, reassessment of changing needs and participant's expressed wishes.
Performs home visits periodically or as needed to asses living environment and support system.
Assists with ongoing financial eligibility for participants, including recertification as needed.
Provide training, supervision, oversight and evaluation to case managers and case management to participants and families.
Acts as liaison between the participant and other agencies such as Department of Aging, Social Security Administration, and Medicaid.
Acts as a resource to other team members, and day center staff regarding topics such as dementia, difficult behaviors, and difficult personalities.
Assists participants and caregivers in filing grievances and appeals.
Assures that any personal care needs are communicated to the family with special attention to clothing and DME needs while participants are in hospital or short-term rehab stays and communicate relevant information to the interdisciplinary team about participants while they are admitted.
Coordinates discharge planning for participants returning home from hospital or nursing facility.
Provides crisis intervention and advocacy as required.
Actively provides emotional support, grief work, education, funeral and financial planning referrals when hospice care is appropriate.
Facilitates hospice or nursing home placement as needed.
Initiates referrals to external resources with community agencies such as Adult Protective.
Assists participants and caregivers to complete Medical Durable Power Of Attorney (MDPOA) Proxy, and Do Not Resuscitate (DNR) directives as needed.
Coordinates transitional care to ensure continuation of care by assisting participants with reinstatement of conventional Medicare and Medicaid benefits, transitions care to other providers, makes referrals, and ensures participant medical records are available to new providers in the event of participant termination of the PACE Program.
Performs other duties as assigned.