Social Worker, Community Health

Salary Range: $63,410.00 To $73,902.00 Annually

• Master’s Degree in social work from an accredited school of social work.
• A minimum of one year’s experience working with a frail or elderly population.
• Compliance with any State or Federal requirements for direct patient care staff in their respective settings.
• Valid driver’s license.
• Pass a criminal background check.
• Medically cleared of communicable diseases and up-to-date with immunizations.

The PACE Social Worker is responsible for the direct social work case management services to PACE participants and will provide social services support to include participant screening, case management, counseling, and referral. The PACE Social Worker evaluates and coordinates new enrollees to the program, including in-take and marketing activities.

• Evaluates potential program enrollees to determine participant needs and eligibility for enrollment.
• Completes intake and enrollment documentation.
• Participates in the Interdisciplinary Teams’ initial assessments, care planning and on-going evaluations of participants.
• Conducts periodic assessments in the home.
• Facilitates the development of the IDT Plan of Care.
• Refers participants to appropriate community agencies or facilitates, acts as a liaison with such organizations and as advocate for participants.
• Coordinates all level of care decisions with State Health and Human Services Personnel.
• Participates in interdisciplinary team, management team, and other related meetings and activities.
• Participates in marketing activities.
• Participates in program and policy development of the social work component of the program.
• Complies with HIPAA requirements and maintains strict confidentiality in all matters pertaining to PACE participants and program operations.
• Completes appropriate documentation related to participant assessments as required.
• Ensures timely, complete communication of referral services into the electronic medical record.
• Assists with staff development and training.
• Participates in the Quality Improvement program.
• Oversees disenrollment process including facilitating a participant’s reinstatement in other Medicare and Medicaid programs and developing a transition plan to community services.
• Complies with Mandated Reporter requirements reporting any suspected abuse, neglect or exploitation to the appropriate authorities.
• Maintains required statistical data.

• Working knowledge of the interdisciplinary model of care management.
• Thorough working knowledge of current community health practice for the frail elderly from direct service experience.
• Possess excellent communication, interpersonal and conflict resolution skills.
• Knowledge of social systems and institutions, and individual behavior.
• Must be able to relate well with seniors and their families to deal with sensitive issues and facilitate problem solving.
• Must be flexible.
• Can apply appropriate interventions to meet the needs of participants and family.
• Knowledge of Medicare/Medicaid regulations.