Social Worker

Appalachian Agency For Senior Citizens Inc • Bristol, VA

10d • $63,410 - $73,902

About The Position

The PACE Social Worker provides direct social work case management services to PACE participants, including screening, case management, counseling, and referrals. The role evaluates and coordinates new enrollees, including intake and marketing activities, and works with interdisciplinary teams to assess participants, plan and coordinate care, and support their needs. The Social Worker also coordinates level-of-care decisions, supports transitions and disenrollment, contributes to program development and quality improvement, and maintains required documentation and statistics.

Requirements

• Master’s degree in social work from an accredited school of social work.
• At least one year of experience working with a frail or elderly population.
• Compliance with applicable State or Federal requirements for direct patient care staff in the relevant settings.
• Valid driver’s license.
• Pass a criminal background check.
• Medical clearance for communicable diseases and up-to-date immunizations.
• Working knowledge of the interdisciplinary model of care management.
• Thorough working knowledge of current community health practice for the frail elderly, based on direct service experience.
• Excellent communication, interpersonal, and conflict resolution skills.
• Knowledge of social systems and institutions, and individual behavior.
• Ability to relate well with seniors and their families when addressing sensitive issues and facilitating problem solving.
• Flexibility.
• Ability to apply appropriate interventions to meet participant and family needs.
• Knowledge of Medicare and Medicaid regulations.

Responsibilities

• Evaluate potential program enrollees to determine participant needs and eligibility for enrollment.
• Complete intake and enrollment documentation.
• Participate in interdisciplinary teams’ initial assessments, care planning, and ongoing evaluations of participants.
• Conduct periodic assessments in participants’ homes.
• Facilitate development of the IDT Plan of Care.
• Refer participants to appropriate community agencies or facilities, serve as a liaison with those organizations, and advocate for participants.
• Coordinate all level-of-care decisions with State Health and Human Services personnel.
• Participate in interdisciplinary team, management team, and other related meetings and activities.
• Participate in marketing activities.
• Participate in program and policy development for the social work component of the program.
• Comply with HIPAA requirements and maintain strict confidentiality regarding PACE participants and program operations.
• Complete appropriate documentation related to participant assessments.
• Ensure timely and complete communication of referral services into the electronic medical record.
• Assist with staff development and training.
• Participate in the Quality Improvement program.
• Oversee disenrollment, including facilitating participant reinstatement in other Medicare and Medicaid programs and developing a transition plan to community services.
• Comply with Mandated Reporter requirements by reporting suspected abuse, neglect, or exploitation to appropriate authorities.
• Maintain required statistical data.

What This Job Offers

• Job Type: Full-time