Social Worker | MSW

Pace Place•Jacksonville, FL

9d•Onsite

About The Position

The PACE Social Worker plans, organizes, and delivers social work services to PACE participants and their families. Working with the interdisciplinary team, the Social Worker assesses participant needs, develops and updates care plans, provides counseling and support, connects participants with community resources, and advocates for their needs to help them continue living in the community. The role also supports care transitions and serves as a liaison among participants, caregivers, the interdisciplinary team, and external agencies. The position is based at PACE Place in Jacksonville, Florida, and is scheduled Monday through Friday, 8:00 a.m. to 5:00 p.m. Compensation is $56,000–$60,000 annually, plus a full benefits package that includes 23 days of annual PTO. PACE Place is a Program of All-Inclusive Care for the Elderly serving select zip codes in Duval and Clay counties. Its interdisciplinary team provides services intended to help frail and elderly participants remain safe and independent at home. Services may include clinical care, therapy, meals, recreational activities, personal care, home health support, care coordination, and transportation to outside specialist appointments.

Requirements

Master’s degree in Social Work from a Council on Social Work Education (CSWE)-accredited program; a minimum of an MSW is required for an interview.
At least one year of experience working with a frail or elderly population, or completion of training upon hire.
Current driver’s license and auto insurance.
CPR with First Aid or BLS certification.
Meet standardized PACE competencies before working independently.
Deep understanding of psychosocial issues affecting frail, elderly, and chronically ill individuals.
Strong assessment, counseling, and case-management skills.
Effective communication and interpersonal skills.
Skilled in documentation and professional writing.
Ability to work collaboratively with an interdisciplinary team.
Proficiency in Microsoft Office applications, including Word, Excel, PowerPoint, and Outlook.

Nice To Haves

Two years of experience on an interdisciplinary team in healthcare or community-based settings is preferred.

Responsibilities

Conduct in-person psychosocial assessments of new and existing participants to identify cognitive, emotional, and support needs.
Collaborate with the interdisciplinary team to develop and update participant care plans.
Attend and actively participate in daily interdisciplinary team meetings and support coordination of 24-hour care delivery.
Provide education, counseling, and support to participants and caregivers on aging, dementia, grief, family dynamics, and disease processes.
Facilitate access to social services and assist with housing, financial support, advance care planning, and legal documents such as MDPOA and DNR.
Perform home, hospital, and facility visits as needed for assessment, support, and discharge planning.
Coordinate transitions in care, including temporary respite, long-term placement, or disenrollment.
Maintain timely and accurate documentation in participant medical records.
Advocate for participants with external agencies, including Adult Protective Services and Housing Authorities.
Assist with grievances, appeals, and Medicaid eligibility processes.
Ensure compliance with regulatory and internal documentation, assessment, and service-delivery requirements.
Participate in continuing education and contribute to quality-improvement efforts.