Senior Services Social Worker

Job Description:

Senior Services Social Worker I

Reports To:

Senior Services Director Supervises:
No One Status:
Non-Exempt

Location:

Access to Healthcare Network – Las Vegas About Access to Healthcare Network (AHN)

Access to Healthcare Network (AHN) is a mission‑driven nonprofit dedicated to improving access to quality healthcare and supportive services. We foster a collaborative, respectful, and dynamic work environment where team members feel valued and supported. Joining AHN means contributing to meaningful work that positively impacts seniors, individuals with disabilities, and underserved community members.

The Senior Services Social Worker I supports older adults and individuals with disabilities in accessing services, resources, and supports that promote independence, community integration and quality of life. This position is primarily assigned to Money Follows the Person (MFP) Program where it serves individuals transitioning from institutional settings, including nursing facilities and other long-term care environments, into community-based living arrangements.

Working in partnership with healthcare providers, community organizations, and housing partners, this position provides person centered transition planning, care coordination, resource navigation and follow-up services to ensure participants achieve safe, successful, and sustainable community living. This position serves as a key member of the MFP team and is responsible for helping participants identify goals, access services and supports, overcome barriers to community reintegration, and maintain independence following discharge from institutional care.

• Conduct comprehensive assessments to identify participant strengths, needs, preferences, and goals related to community living.
• Develop and implement person-centered transition plans in collaboration with participants, family members, facility staff, and community partners.
• Coordinate services necessary for community reintegration, including healthcare, behavioral health, transportation, nutrition, housing, and long-term support services.
• Facilitate communication among providers and stakeholders to ensure seamless transitions and continuity of care.
• Participate in interdisciplinary team meetings and case conferences as required.

• Maintain regular contact with participants before, during, and after transition to community living.
• Monitor participant progress and service delivery to ensure needs are being met.
• Identify and address barriers that may impact successful transition outcomes.
• Assist participants in obtaining benefits, services, and community resources.
• Provide education regarding available supports, rights, choices, and self-advocacy.

• Build and maintain relationships with nursing facilities, hospitals, housing agencies, social service organizations, and community providers.
• Connect participants to appropriate community resources and services.
• Collaborate with state and local partners to improve access to community-based services and supports.
• Participate in outreach, education, and networking activities that promote MFP services and objectives.

• Follow all MFP program requirements, policies, and procedures.
• Maintain accurate, timely, and complete participant records in accordance with program, agency, and regulatory requirements.
• Document assessments, service plans, referrals, participant contacts, and outcomes.
• Track participant progress and required program data for reporting purposes.
• Ensure compliance with all applicable confidentiality requirements, including HIPAA.

• Provide case management…