Social Worker, LMSW - PACE (Full-Time)

Hudson Headwaters Health Network•City of Glens Falls, NY

About The Position

The PACE Social Worker (LMSW) is a member of the Program of All-Inclusive Care for the Elderly (PACE) Interdisciplinary Team (IDT). PACE provides coordinated medical and social services to eligible older adults who wish to continue living in their homes despite chronic care needs. The social worker completes comprehensive initial social work assessments for new participants and reassessments for existing participants as part of the IDT care-planning process. The role provides direct social work and care management services in collaboration with the IDT and current care plans. Services include social work screenings, case management, counseling coordination, and referrals to community agencies. The social worker maintains knowledge of local community resources and services for participants and caregivers, and educates participants, caregivers, and PACE staff about psychosocial factors and participant-caregiver dynamics that affect care.

Requirements

Master’s degree in Social Work from an accredited college or university.
Current New York State license and certification as a Licensed Master of Social Work (LMSW).
At least one year of post-MSW experience.
At least one year of experience working with a frail or elderly population, or, if lacking that experience, completion of appropriate PACE program training on working with a frail or elderly population before providing direct participant care.
Demonstrated skills and knowledge outlined in social worker competency requirements.
Excellent interpersonal skills and ability to work cooperatively on an interdisciplinary team.
Highly organized, able to prioritize tasks, and able to conduct thorough follow-up.
Excellent written and verbal communication skills.
Proficient computer skills, including Microsoft applications and the ability to navigate electronic health record platforms.
Ability to work independently and collaborate and communicate effectively with colleagues, supervisors, service delivery partners, other health care professionals, and co-workers to build and maintain effective professional team relationships.
BLS certified or willing to complete the necessary certification.
Valid driver’s license.
Medical clearance for communicable diseases and up-to-date immunizations and vaccines before engaging in participant care.
Must not have been convicted of criminal offenses involving Medicaid, Medicare, other health insurance or health care programs, or social services programs under Title XX of the Act.
Must not have been convicted of criminal offenses pertaining to physical, sexual, drug, or alcohol abuse.
Must not be excluded from participating in Medicare and Medicaid programs.

Nice To Haves

At least two years of experience in a health-related area is preferred.

Responsibilities

Participate as a PACE Interdisciplinary Team (IDT) member and complete comprehensive initial social work assessments and other identified assessments for new participants, as well as social work reassessments for existing participants.
Collaborate with the IDT to develop social work care plans and deliver interventions that address participants’ medical, physical, social, and emotional needs.
Coordinate 24-hour care delivery with the IDT and support participants’ psychosocial well-being; identify, provide, and coordinate medically related social, psychological, and spiritual needs.
Implement or coordinate social work interventions, case management, individual and caregiver counseling, and comprehensive psychosocial support.
Consult with and advise PACE staff about social, emotional, and cultural factors affecting access to health care, medical care, and community resources.
Refer participants and families to appropriate community resources, liaise with those organizations, and advocate for participants in collaboration with the IDT.
Monitor participants for health or psychosocial changes requiring reassessment and promptly communicate relevant changes to the IDT.
Provide ongoing support and education to participants and caregivers regarding aging, dementia management, grief and loss, end-of-life considerations, disease processes, family dynamics, and the PACE service delivery model.
Complete and maintain social work documentation in the PACE EHR in accordance with federal PACE regulations and organizational policy.
Attend IDT and morning meetings and report on participants’ social status.
Maintain knowledge of Medicaid financial eligibility criteria and required documentation, participant liability and applicable share of cost, and applicable state nursing home Level of Care requirements.
Support the PACE Quality Improvement program and participate in assigned quality improvement activities.
Perform other duties as assigned.