Social Worker, LMSW

Distro•New York, NY

4d•Onsite

About The Position

We are seeking a compassionate, organized, and clinically skilled Social Worker, LMSW to provide psychosocial assessment, care management, counseling coordination, participant advocacy, caregiver support, and community-resource coordination. As a member of the Interdisciplinary Team, the Social Worker completes comprehensive initial assessments for new participants and reassessments for existing participants; identifies psychosocial needs; develops social work components of individualized care plans; coordinates interventions; monitors changes in participant status; and advocates for participants and caregivers throughout care. Recommendations and services should account for participants’ medical, physical, emotional, social, cultural, spiritual, financial, and family circumstances. The Social Worker also educates participants, caregivers, and staff about aging, dementia, grief and loss, end-of-life considerations, chronic disease, family dynamics, and the care model. The position requires an active New York State LMSW license, at least one year of post-MSW experience, strong electronic documentation skills, and the ability to work independently and contribute effectively to an interdisciplinary healthcare team. This is a full-time, exempt position with a proposed schedule of 40 hours per week, Monday through Friday, 8:00 a.m. to 4:30 p.m. Annual salary is $70,000. Details about benefits, paid time off, retirement, and insurance eligibility are to be confirmed before the public posting is finalized. The role includes completing and documenting assessments and reassessments; participating in interdisciplinary care planning; providing case-management and care-coordination services; coordinating counseling and psychosocial support; educating participants, caregivers, and staff; making and following up on community referrals; advocating for participants; monitoring changes and caregiver needs; supporting Medicaid financial eligibility and New York State nursing home Level-of-Care requirements; maintaining accurate and confidential Electronic Health Record documentation; and supporting Quality Improvement activities. Before providing participant care, the selected candidate must complete required medical clearance, maintain required immunizations and vaccinations, meet applicable screening requirements, and maintain required professional licensure, certification, and employment eligibility. Candidates must not have specified disqualifying convictions or be excluded from Medicare or Medicaid participation. The position requires a valid driver’s license and ability to travel or drive as required. The Social Worker must be able to perform essential job functions safely and successfully, with reasonable accommodations potentially available as required by law.

Requirements

Master’s degree in Social Work from an accredited college or university.
Current New York State license and certification as a Licensed Master Social Worker (LMSW), maintained throughout employment.
At least one year of post-MSW professional experience.
Candidates without one year of experience working with a frail or older adult population must complete appropriate provided training before delivering direct participant care.
Strong psychosocial assessment and care-planning skills.
Ability to provide case-management and counseling-coordination services.
Excellent interpersonal, written, and verbal communication skills.
Ability to work cooperatively within an interdisciplinary team and independently.
Strong organization, prioritization, and follow-up skills.
Ability to communicate effectively with participants, caregivers, colleagues, supervisors, service-delivery partners, and healthcare professionals.
Ability to build effective professional relationships and maintain confidentiality and professional boundaries.
Participant-centered and culturally responsive approach to care.
Proficiency with Microsoft applications and ability to learn and navigate Electronic Health Record platforms.
Strong clinical-documentation skills and ability to maintain accurate electronic records.
Comfort using technology for meetings, communication, care coordination, referrals, and documentation.
Current BLS certification or willingness to complete the required certification.
Valid driver’s license and ability to travel or drive as required.
Complete required pre-employment medical clearance and maintain required immunizations, vaccinations, screening eligibility, professional credentials, and employment eligibility.
Must not have disqualifying convictions involving specified healthcare or social-services programs or physical abuse, sexual abuse, drug abuse, or alcohol abuse, and must not be excluded from Medicare or Medicaid participation.
Ability to safely and successfully perform the essential functions of the position, with reasonable accommodations potentially available as required by law.

Nice To Haves

At least one year of experience working with a frail or older adult population.
Two or more years of experience in a health-related setting.
Experience working with frail or medically complex older adults.
Experience in geriatric, home-care, adult-day-health, skilled-nursing, rehabilitation, hospice, hospital, behavioral-health, or community-health settings.
Experience conducting comprehensive psychosocial assessments.
Experience supporting individuals with dementia and their caregivers.
Experience with grief, loss, chronic illness, and end-of-life conversations.
Knowledge of Medicaid eligibility and participant share-of-cost requirements.
Knowledge of New York State nursing home Level-of-Care requirements.
Experience using Electronic Health Records.
Experience coordinating community resources and social-service referrals.
Current BLS certification.
Strong knowledge of aging services and community resources.

Responsibilities

Complete comprehensive initial social work assessments for new participants and required reassessments for existing participants, including additional assessments when circumstances change.
Assess participants’ emotional, social, cultural, behavioral, environmental, financial, spiritual, and family circumstances, including strengths, risks, needs, preferences, and support systems.
Identify barriers affecting care access, treatment adherence, safety, independence, or community living; document findings and communicate significant concerns to the Interdisciplinary Team (IDT).
Develop the social work components of individualized care plans and recommend, coordinate, monitor, and update participant-centered interventions.
Participate actively in IDT, participant-review, care-planning, and morning meetings; report relevant changes and help keep care plans coordinated and responsive.
Provide direct social work and care-management services in accordance with participants’ care plans.
Coordinate social, psychological, emotional, and spiritual support; help participants and caregivers navigate healthcare, benefits, housing, transportation, social-service, and community-resource systems.
Follow up on referrals, confirm access to approved services, identify service gaps, and maintain communication with participants, caregivers, providers, and the IDT.
Provide or coordinate individual counseling and supportive interventions within the scope of the LMSW role; support people experiencing aging-related adjustment, disability, chronic illness, loss, caregiver stress, family conflict, or emotional distress.
Identify behavioral-health, safety, abuse, neglect, or crisis concerns and escalate them according to organizational policy and applicable requirements.
Educate participants and caregivers about aging, dementia, cognitive changes, disease processes, grief, loss, end-of-life considerations, the service-delivery model, care expectations, and available supports.
Educate staff about participant and caregiver dynamics affecting care, communicate complex psychosocial topics clearly, and reinforce participant choice, dignity, autonomy, and informed involvement.
Maintain knowledge of community resources; refer participants to appropriate organizations and coordinate resources related to housing, benefits, behavioral health, caregiver support, social services, legal assistance, food access, transportation, and other needs.
Advocate for participant rights, preferences, dignity, safety, self-determination, and access to appropriate services; help communicate concerns and resolve barriers.
Monitor changes in participant health, psychosocial status, behavior, emotional well-being, family support, and living circumstances; reassess and update goals or interventions as needed.
Monitor caregiver availability and stress, identify emerging risks to safe community living, and follow up on unresolved psychosocial concerns.
Maintain working knowledge of Medicaid financial eligibility, documentation, participant liability, and share-of-cost requirements; help participants understand processes and escalate complex questions appropriately.
Maintain knowledge of New York State nursing home Level-of-Care requirements and support the collection and communication of relevant psychosocial information for participant review and care planning.
Complete timely, accurate, complete, and objective social work documentation in the Electronic Health Record; document assessments, interventions, referrals, communications, participant status, and follow-up while protecting confidentiality.
Support the Quality Improvement program by participating in assigned activities, identifying improvement opportunities, contributing social work information to quality reviews, and following corrective-action and process-improvement requirements.
Travel or drive as required to fulfill participant-care and program responsibilities.