PACE - Social Worker

PACE Place provides coordinated medical and social services to elders who want to remain in their home but need support to do so. PACE Place provides Medical, Rehabilitation, In-Home Assistance, Transportation, Social Work, and Day Center services for patients in our care. Position Summar The PACE Social Worker (MSW) is responsible for planning, organizing, and delivering social work services to participants and their families enrolled in the PACE program.

Key responsibilities include conducting comprehensive psychosocial assessments, developing and implementing care plans in collaboration with an interdisciplinary team, providing individual and family counseling, facilitating access to community resources, and advocating for participant needs to support continued community living. The MSW also plays a critical role in care transitions and serves as a liaison among participants, caregivers, the interdisciplinary team, and external agencies.

Essential Functions Conduct in-person psychosocial assessments for new and existing participants to identify cognitive, emotional, and support needs. Collaborate with the interdisciplinary team to develop and update participant care plans. Attend and actively participate in daily interdisciplinary team meetings and support the coordination of 24-hour care delivery, including after-hours on-call responsibilities. Provide education, counseling, and support to participants and caregivers on topics such as aging, dementia, grief, family dynamics, and disease processes.

Facilitate the use of social services and assist with housing, financial support, advance care planning, and legal documents (e.g., MDPOA, DNR). Perform home, hospital, and facility visits as needed for assessment, support, and discharge planning. Coordinate transitions in care including temporary respite, long-term placement, or disenrollment. Maintain timely and accurate documentation in participant medical records. Advocate for participants with external agencies such as Adult Protective Services and Housing Authorities.

Assist with grievances, appeals, and Medicaid eligibility processes. Ensure compliance with all regulatory and internal documentation, assessment, and service delivery requirements.

Participate in continuing education and contribute to quality improvement efforts. Qualifications Knowledge and Critical Skills Deep understanding of psychosocial issues affecting frail, elderly, and chronically ill individuals. Strong assessment, counseling, and case management skills. Effective communication and interpersonal skills. Skilled in documentation and professional writing. Ability to work collaboratively with an interdisciplinary team. Proficient in Microsoft Office applications including Word, Excel, PowerPoint, and Outlook.

Experience At least one year of experience working with a frail or elderly population (or must complete training upon hire). Preferably two years of experience on an interdisciplinary team in healthcare or community-based settings. Must meet standardized PACE competencies prior to working independently. License / Certification Current driver's license and auto insurance. CPR with First Aid or BLS certification required.

ACSW or other NASW-recognized certification preferred. Education Master's degree in Social Work from a Council on Social Work Education (CSWE)-accredited program. Other Requirements Medical clearance and current immunizations. Ability to lift/carry up to 30 pounds using proper body mechanics. Must be able to work in various settings, including homes, clinics, and nursing facilities. Must maintain participant confidentiality and adhere to safety protocols.

The knowledge, skills and abilities listed above are typically acquired through the levels of education and experience listed. However, any equivalent combination of education and/or experience, which provide an applicant with the listed knowledge, skills, and abilities to perform the essential duties and responsibilities of the job, is acceptable.

This description is intended to describe the general nature and level of work performed by employees assigned to this role. It is not intended to be…