Social Worker
About The Position
The PACE Social Worker serves as a core member of the PACE Interdisciplinary Team (IDT) through the provision of a wide range of social work services to program participants and their caregivers. This role involves providing care in various settings, including the PACE center, participants' homes, hospitals, and nursing facilities. The Social Worker will offer supportive counseling, conduct comprehensive assessments, develop care plans, and collaborate with other team members and community resources to ensure participants' holistic well-being. Key responsibilities include acting as a liaison, coordinating care, supporting end-of-life transitions, organizing support groups, completing documentation, and potentially supervising interns.
Requirements
- Master’s degree in Social Work with LCSW/LICSW licensure (or completion of LCSW/LICSW within 6 months of start date).
- Knowledge of dual diagnosis treatment, harm reduction, trauma informed care, motivational interviewing, and the recovery model.
- Basic computer skills (EMR, internet, and documentation).
- Two years of experience working with older adults in a community or medical setting preferred.
- Experience and interest in supporting a diverse population of older adults.
- Strong communication and people skills.
- Comfortable working as part of a team.
- Ability to assess needs and problem-solve.
- Familiarity with community resources and services.
- Culturally respectful and participant-centered approach.
- Clear and accurate documentation skills.
- Ability to handle sensitive and emotional situations professionally.
- Commitment to equitable and culturally appropriate care for a wide range of diverse populations, including (but not limited to) communities with high needs, people with histories of incarceration, individuals with substance use disorders and behavioral health challenges, and those experiencing homelessness.
- Bilingual in English/Spanish a plus.
- Interest in working in a collaborative, team environment.
Nice To Haves
- Two years of experience working with older adults in a community or medical setting preferred.
- Bilingual in English/Spanish a plus.
Responsibilities
- Provide care to a caseload of older adults and their caregivers in a variety of settings including the PACE center, their homes, hospitals and nursing facilities.
- Provide in-person, telephonic, and virtual supportive counseling to participants, families, and caregivers.
- Conduct initial, bi-annual, and unscheduled comprehensive assessments of participants.
- Develop and implement fluid, participant centered care plans.
- Collaborate with the Community Resource Specialist to support participants in completing their case management needs.
- Work closely with the Behavioral Health Therapist and Chaplain to ensure that participant’s mental and spiritual wellness needs are supported.
- Attend daily meetings with the PACE IDT.
- Contribute to the problem-solving process of participant care issues using social work values and principles.
- Act as liaison between the IDT and caregivers.
- Orient participants, families, and caregivers to PACE services.
- Coordinate care with outside providers and programs.
- Play an active role in the end-of-life transition for participants, families, and caregivers.
- Identify, organize, and implement support groups for participants and caregivers.
- Complete documentation in accordance with Upham’s PACE and CMS standards.
- Supervise Social Work Interns as needed.
- Present ethical dilemmas at quarterly Ethics Committee meetings.
- Perform other duties as required by the position and/or as assigned by the Manager of Social Work.
Benefits
- Commensurate with experience and licensing; including other factors, such as language, certifications, etc.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
