Social Worker, Mental Health

The Social Worker (CSW) at the PACE Your LIFE Program contributes the profession’s unique psychosocial perspective to the interdisciplinary evaluation, assessment, plan of care, ongoing services, and disenrollment processes that occur once PACE participants begin intake and continue with ongoing services. The CSW provides basic casework and consultation for the PACE participants, as well as facilitates communication between participants, their family, and the PACE Interdisciplinary Team (IDT).

The CSW ensures efficient and appropriate coordination of care to optimize the health status and quality of life of PACE participants. The CSW’s interventions may include participant and family education, assessment and counseling, resource mobilization, addressing mental health needs, ongoing case management, and advocacy to ensure participants’ needs are met, and disenrollment procedures are followed.

• Full-Time

• Medical
• Dental
• Vision
• PTO + 6 paid holidays
• 401k after 1 year of employment

1. Uses all information sources available, assesses participants’ psychosocial health status and social work needs.

a. Completes assessments at admission and for required care planning according to regulatory requirements and as condition changes indicate.

b. Determines participant and family needs related to social support, financial support, counseling, and housing.

c. Confers with participant and family to identify participant goals and expectations.

d. Coordinates with the Interdisciplinary Team to develop a comprehensive care plan for each participant.

2. In cooperation with the Interdisciplinary Team, plans and performs psychosocial interventions designed to keep the participant in the community and enhance quality of life to the greatest extent possible.

3. Provides individual and group counseling to participants and their families as needed or prescribed in the care plan.

4. Assists in the completion of participants’ healthcare wishes and advance directives in cooperation with their primary care physician and/or nurse practitioner, the participant and family.

5. Provides discharge planning in the event of disenrollment.

6. Acts as participant advocate and liaison between participant and various governmental and private agencies to maximize the participant’s support network and obtain needed services:

a. Facilitates communication between participants and various government programs such as Medicaid, SSI, Medicare, and Social Security.

b. Reviews Medicaid eligibility, monitors time frame for recertification.

c. Facilitates Medicaid applications for certification and recertification in conjunction with the Medicaid Eligibility Specialist.

7. Participates in interagency meetings as needed and assists participants in obtaining housing and eligibility for low‑income housing options.

8. Evaluates the need for and assists with the set‑up of money management systems for participants who require assistance.

9. Keeps up-to-date on changing rules and regulations regarding Medicaid and Medicare eligibility and other entitlement programs and services.

10. Acts as participants’ advocate and liaison between participant, family, and Care Team:

a. Facilitates communication between participant, family, and Care Team to maximize or maintain participant support systems.

b. Facilitates or participates in family meetings as required.

11. Facilitates the Participant Council to create and maintain a vehicle for dialogue between participants and the Care Team, and to empower participant responsibility.

12. Conducts family support groups, education or training sessions, and routine family caregiver meetings for education, support, and dialogue.

13. Works with the Program Director to provide orientation and in-service programs for the Care Team to enhance staff understanding of psychosocial issues and to meet regulatory requirements and support performance improvement.

14. Coordinates with mental health-related providers, including drug and alcohol treatment, to arrange appointments and share pertinent information.

15. Participates in surveys and inspections made by authorized government agencies.