Social Worker

On Lok•San Jose, CA

18d•Hybrid

About The Position

On Lok PACE is a non-profit organization dedicated to the care of elders through the Program of All-Inclusive Care for the Elderly (PACE). The PACE model emphasizes serving seniors with chronic care needs and their families within their community. On Lok PACE addresses challenges such as transportation, medication management, coordination of medical care, social isolation, and the ability to live independently. Participants receive in-home care services and transportation to a PACE center for medical care, social activities, and other senior services. The organization seeks individuals whose expertise, drive, and passion can help improve lives and advance healthcare. The Social Worker provides direct case management services, assisting participants and their families/caregivers with social, emotional, and practical issues to maintain independence. As a member of the Interdisciplinary Team (IDT), the Social Worker conducts assessments, coordinates care, develops treatment plans, and provides referrals to community resources.

Requirements

Graduate of an accredited college with a Master's of Social Work degree.
Minimum one-year experience with the frail or elderly.
Experience or ability in working with a diverse population.
Experience working within the framework of an interdisciplinary team.
Good interpersonal skills, including the ability to work cooperatively on an interdisciplinary team.
Highly organized, able to prioritize tasks and conduct thorough follow-up.
Excellent written and verbal communication skills.
Computer literate with basic knowledge of Microsoft Office.
Bilingual ability may be required for specific assignments.

Nice To Haves

Experience with electronic health record system (preferred).
Minimum one-year post MSW experience (preferred).
Minimum one-year case management experience (preferred).
Minimum one-year health care related experience (preferred).

Responsibilities

Provide case management to a panel of participants using independent judgment and discretion.
Conduct initial and routine psychosocial assessments to develop, implement, and update individualized care plans and interventions.
Partner with caregivers and support systems to develop care plans and deliver services.
Identify risks and psychosocial problems.
Assess service needs, advocate, refer, coordinate, and follow up on participant needs in a timely manner.
Provide individual counseling.
Facilitate family conferences.
Connect with the community to meet participants' specific needs.
Assess needs and complete discharge planning for dis-enrolling participants.
Facilitate participant and/or caregiver groups and participate in special events.
Serve as the main liaison between participants, caregivers, the team, and the community.
Collaborate with relevant departments such as Health Plan and other community agencies.
Adhere to all ethical and legal standards of social work practices.
Comply with all On Lok policies and procedures, including PACE, safety, and confidentiality requirements.
Complete all documentation requirements accurately and in a timely manner.
Actively participate in team meetings, advocate for participants and caregivers, resolve differences, and support team plans.
Incorporate Healthcare Hospitality G.R.E.A.T. Practices for 5-Star service.
Assist in the continuous quality improvement of social work services and system efficiency.
Perform other reasonably related duties as assigned.