Social Worker

Seen Health • Alhambra, AZ

4d

About The Position

Seen Health is a culturally focused, technology-enabled healthcare organization delivering senior care through the PACE (Programs of All-Inclusive Care for the Elderly) model. Its mission is to help seniors age in place with dignity while supporting their families through comprehensive medical care and social services.

The Social Worker plans, organizes, and implements social work services for PACE participants, serving a significant Chinese-speaking elderly population in the San Gabriel Valley. The role conducts psychosocial assessments, develops individualized care plans, provides case management and supportive counseling, coordinates integrated and culturally and linguistically responsive care, and communicates with participants and family caregivers about care needs, behavioral health, services, transitions, and treatment or discharge plans. The position also arranges social services and community resources, supports behavioral management and discharge planning, maintains clinical records, participates in interdisciplinary team meetings and quality improvement, and ensures compliance with PACE requirements and applicable regulations. Regular travel throughout the San Gabriel Valley is required.

Requirements

• Master’s degree in Social Work.
• One year of experience in the job offered or a healthcare social worker-related occupation.
• Associate Clinical Social Worker licensure.
• One year working with frail and elderly populations.
• Experience conducting psychosocial assessments, care planning, and case management.
• Experience assisting people with behavioral health and substance abuse issues.
• Fluency in Chinese (Mandarin or Cantonese).

Responsibilities

• Plan, organize, and implement comprehensive social work services for participants enrolled in the PACE program.
• Conduct psychosocial assessments to evaluate participant needs.
• Develop and implement individualized care plans.
• Provide ongoing case management and supportive counseling to participants and their families, including Chinese-speaking participants and family caregivers.
• Coordinate care with physicians, nurses, therapists, caregivers, and community service providers.
• Communicate with participants and family caregivers about care needs, behavioral health concerns, available services, care transitions, and treatment and discharge planning.
• Arrange social services and community resources.
• Facilitate care transitions, support behavioral management strategies, and assist with discharge planning.
• Maintain accurate clinical documentation in electronic health record systems.
• Participate in interdisciplinary team meetings and quality improvement activities.
• Ensure compliance with PACE program requirements and applicable regulatory standards.
• Travel to physicians’ offices, hospitals, community organizations, outreach events, and other settings throughout the San Gabriel Valley.

What This Job Offers

• Job Type: Full-time