Mission
The Social Worker agrees to support the mission and core values of Serenity Care PACE.
Job Summary
Under the direction of the PACE Director, is responsible for direct social work case management services to participants.
Essential Job Functions
• Conduct the initial intake and assesses need and eligibility of potential clients, meeting with family members and others.
• Serve as a member of the interdisciplinary team and participate in the initial assessment process, service plan of care development and ongoing monitoring of each client's care.
• In conjunction with the interdisciplinary team, coordinate family meetings.
• Provide crisis intervention and advocacy as required.
• Provide individual and family counseling as needed or prescribed in the plan of care; develop and lead group counseling and support activities.
• In conjunction with the interdisciplinary team, coordinate discharge planning for clients returning home from hospital or nursing home.
• Maintain current, written case management records, including ongoing documentation of services provided, reassessment of changing needs and client's expressed wishes.
• Act as liaison between the participant and other agencies such as Department of Aging, Social Security Administration, Medicaid, etc.
• Assist with money management.
• Obtain extensive social history from participant and/or family member upon admission to program.
• Maintain confidentiality of client information.
• Assist with ongoing financial eligibility for participants including recertification as needed.
• Initiate in home, group home and nursing home assessments.
• Participate in participant-related conferences in the community as designated.
• Perform related duties as assigned. Non-Essential Job Functions
• Attend and participate in all staff meetings, in-services, projects and committees as assigned.
• Adhere to and support the facilities’ policies, practices and procedures.
• Accept assigned duties in a cooperative manner and perform all other related duties assigned.
• Must be flexible in schedule of hours worked.
• May require use of personal vehicle.
Qualifications and Requirements
Education: A Master’s Degree in Social Work required. Must be licensed (LicSW or MSW) in the State in which the PACE Organization is located.
Experience: Minimum of one (1) year demonstrated successful experience in working with a frail or elderly population required. Prefer experience in a community-based setting or geriatric program.
Skills and Knowledge
• Experience and thorough knowledge of social service principles and practices.
• Knowledge of psychosocial, behavioral, and family needs of the elderly population.
• Knowledge of financing mechanisms such as Medicare, Medicaid, Prospective Payment Systems.
• Knowledge of the PACE Organization County health and social service delivery systems, and aging network.
• Effective oral and written communication skills.
• Proven ability to work in an interdisciplinary team.
• Computer skills required.
Desired Personal Attributes
• Interest in the risk-based long-term care program to serve frail elderly in a community-based setting.
• Ability to work effectively and harmoniously with the staff, the elderly and providers of services, public and private agencies.
• Energetic, dependable, resourceful and flexible.
Working Conditions/Physical Demands
The working conditions and physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Ability to access all areas of the facility throughout the workday. Ability to lift up to 35 pounds occasionally, 15 pounds frequently and 7 pounds constantly. The Social Worker is required to obtain assistance of another qualified employee when attempting to lift or transfer objects over 25 pounds. Requires constant hand grasp and finger dexterity; frequent sitting, standing, walking and repetitive leg and arm movements, occasional bending, reaching forward and overhead; squatting and kneeling. Ability to communicate verbally with an excellent comprehension of the English language. Work is generally performed in an indoor, well-lighted, well-ventilated, heated and air-conditioned environment.
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