Social Worker

WelbeHealth•Pasadena, TX

11d

About The Position

At WelbeHealth, each participant of our program is guided by our interdisciplinary team (IDT) - composed of clinical and non-clinical members who work cohesively to provide quality comprehensive primary care and social services for frail seniors to keep them living safely in the community. Our values and participant focus lead the way no matter what. Reporting to the Social Work Manager, the Social Worker maintains a caseload of participants working in close coordination with the IDT. In addition to delivering standard social work services such as psychosocial assessments, care planning, counseling and case management, the Social Worker functions as a liaison between participants, family members, support networks, and care teams as appropriate. This role is different because Social Workers at WelbeHealth: Act as an integral member of an IDT rather than working on an island Collaborate with LCSWs on complex behavioral health issues Establish deep relationships with participants on caseload Help participants age safely and independently in their homes with community resourcing LCSW hours supervision available after 6 months of employment at no cost On the day-to-day, you will: Conduct social work assessments to determine the psychosocial needs, preferences, and goals of participants, and actively participate in IDT meetings to develop participant care plans Deliver and document social work interventions as agreed upon in participants’ care plans, including but not limited to arranging necessary resources and services, assisting with care transitions, providing individual and group counseling, and case management Partner with the Primary Care Physician and other IDT members to guide smooth care transitions between settings (e.g., hospitals, skilled nursing facilities, home) Initiate, coordinate, and facilitate care conference meetings to ensure the highest level of care coordination among other care team members, participants, and people within the participants’ support network (family, informal caregivers, etc.) Provide discharge planning when participants disenroll from the program

Requirements

Master’s degree in social work (MSW) required

Nice To Haves

Minimum of one (1) year of experience working with a frail or elderly population preferred
Experience coordinating and facilitating care conference meetings preferred
Experience assisting people with behavioral health or substance abuse issues preferred

Responsibilities

Conduct social work assessments to determine the psychosocial needs, preferences, and goals of participants, and actively participate in IDT meetings to develop participant care plans
Deliver and document social work interventions as agreed upon in participants’ care plans, including but not limited to arranging necessary resources and services, assisting with care transitions, providing individual and group counseling, and case management
Partner with the Primary Care Physician and other IDT members to guide smooth care transitions between settings (e.g., hospitals, skilled nursing facilities, home)
Initiate, coordinate, and facilitate care conference meetings to ensure the highest level of care coordination among other care team members, participants, and people within the participants’ support network (family, informal caregivers, etc.)
Provide discharge planning when participants disenroll from the program