Social Worker, MSW

InnovAge•Lakewood, CO

14h•Onsite

About The Position

The Social Worker, MSW plans, organizes, and implements social work services for participants and their caregivers in accordance with InnovAge policies and applicable regulations. The role conducts psychosocial assessments, participates in care planning, and serves as a liaison between participants and the interdisciplinary team. Work is on-site at a center and field-based, including visits to participants’ homes and other locations, to ensure continuity of care and support. The Social Worker supports participants and caregivers through assessment, case management, care coordination, psychosocial support, advocacy, documentation, and collaboration with the interdisciplinary team and community partners. The role also assists participants with transitions between residences and care facilities, end-of-life coordination, Medicaid eligibility, grievances, and appeals. Travel may be required, including overnight travel locally or out of state.

Requirements

Master’s degree from a school of social work accredited by the Council on Social Work Education.
One year of experience in a health care setting.
At least one year of experience working with frail or elderly individuals.
Experience conducting psychosocial assessments, care planning, and case management.
Personal transportation, a current state-issued driver’s license, a good driving record, and auto insurance as required by law.
For New Mexico: Licensed Master Social Worker (LMSW) or Licensed Clinical Social Worker (LCSW) licensure through the New Mexico Board of Social Work; the posting specifically states an LMSW license.
For California only: CPR/BLS and First Aid are required.

Nice To Haves

Three or more years of social work experience.

Responsibilities

Conduct initial psychosocial assessments, including SLUMS, PHQ-9, housing, food, financial security, and MDPOA or decision-maker status.
Complete in-person reassessments at least every six months or as required.
Perform in-home visits as required by regulations or indicated by participant needs.
Participate in IDT meetings, morning huddles, mini-teams, and PDPM meetings to support coordinated care.
Facilitate and document participant care conferences, family meetings, and facility partnership meetings.
Participate in discharge planning and plan-of-care development, ensuring problems, interventions, and goals are clearly defined.
Support participants transitioning between residences or care facilities, including arranging transportation and coordinating moves when no support system is available.
Serve as the primary liaison between participants or families and the IDT, facilitating communication and resolution of care issues.
Coordinate respite SNF and ALF admissions, transportation, discharge planning, respite scheduling, and supported placement transitions.
Document housing encounters in EPIC and obtain SNF/ALF updates for the IDT.
Collaborate with the comfort care team on end-of-life activities and assist families with end-of-life coordination.
Collaborate with RN Case Management on hospitalizations and provide psychosocial input; may serve as a back-up to RNCM.
Review participant and family concerns with the Ombudsman, escalate facility quality concerns, maintain admission holds at facilities with care issues, and manage urgent rehousing when contracts terminate.
Coordinate guardianship for participants who lack decision-making capacity and have no surrogate.
Provide options counseling when appropriate.
Assist participants who are disenrolling with timely referrals to external services and completion of disenrollment paperwork.
Provide counseling and psychosocial support in coordination with behavioral health for participants and caregivers as indicated.
Complete comfort care assessments and provide guidance on transitions to end-of-life services.
Advocate for participants living in unsafe housing conditions.
Contribute to RCAs, incident reporting, and follow-up involving abuse, neglect, exploitation, and elopements.
Assist participants and caregivers with grievances and appeals, explaining rights and processes.
Notify participants of and explain participant rights regarding Level of Care denials or disenrollment declines.
Maintain accurate and timely documentation in Epic, EireneRx, and other systems, including demographic, address, telephone, and chart updates.
Complete PASSR screenings, supportive housing forms, and similar documents required by federal and state agencies within regulatory timelines.
Support Medicaid eligibility recertification and partner with Eligibility Financial Determination teams to explain documentation needed to maintain or restore Medicaid eligibility.
Complete dictation and assist with resource compliance.
Report disenrollments accurately and promptly in required systems.
Escalate to the Center Director when service recovery is needed for a participant concern or disenrollment.
Ensure participant care coordination complies with CMS, HCPF, and InnovAge policy requirements.
Participate in IDT and department meetings, cross-site collaboratives, trainings, and annual competencies.
Provide community education and participate in external support groups, inter-agency coordination, and partnership meetings with RCFEs as indicated.
Coordinate with facilities on participant needs.
Provide caseload coverage as assigned for MSW paid time off, open FTEs, and general team needs.
Perform other duties as assigned.