Social Worker, Mental Health

The PACE-RI Social Worker is a core member of the PACE Interdisciplinary Team. Working collaboratively with PCPs, RNs, other professional disciplines, and PACE participants, the Social Worker supports and advocates for the participants in achieving their health and social goals. The Social Worker conducts assessments and provides education and psychosocial support for participants and caregivers of the PACE program. The social worker provides case management services, ensures the participants’ perspective is central to the plan of care, that their rights are respected, and that they remain safe where they reside.

• Provide orientation, information, and resources in response to inquiries from members of the community, participants and their caregivers about Traditional Adult Day and PACE policies, services and facilities.
• Social worker assigned a Traditional Adult Day caseload collaborate with day center staff to enroll participants, determine insurance eligibility, and when applicable, enters participant information into the SAMS electronic system for the co-pay program as required by the Dept. of Healthy Aging.
• Conduct comprehensive biopsychosocial assessments in accordance with program policies, procedures and regulatory standards.
• Assist in the development and delivery of a community- based care plan and related services package necessary to maintain/improve the health of the participant in coordination with participants/ caregiver and care team.
• Attend intake meetings and provide input/ feedback about potential enrollees based on Social work assessment as assigned.
• Serve as a liaison between IDT, service providers and participant/caregivers to ensure timely and effective communication regarding a participant’s service package, plan of care and change of status.
• Coordinate respite stays and discharge planning with staff.
• Monitor community long-term care services provided to the participants for adherence to plan of care and participates in care conferences at skilled nursing facilities to ensure continuity is maintained during short-term and long-term stays.
• Assist in identifying behavioral health needs, provide and oversee behavioral health services, including serving as a liaison with contracted behavioral health providers, and developing behavioral health interventions.
• Identify the need for caregiver support and offer community resources and/or facilitates support and educational groups.
• Provide staff and participants education in group programs as assigned.
• Make protective service reports in accordance to state and federal laws.
• Social worker assigned a Traditional Adult Day caseload complete public and private insurance and State of Rhode Island co-pay program recertification documentation.
• Assist participants with accessing and maintaining entitlement benefits (e.g. housing, Medicaid, and SNAP benefits, etc.) and PACE rep payee program.
• Social worker assigned a Traditional Adult Day caseload assist with other aspects of the Traditional Adult Day programming (e.g. activities department) as needed.
• Assist participants and their families with disenrolling from PACE and Traditional Adult Day program and make arrangements for continuity of care.
• Document all interactions with participants, families, and other stakeholders in the electronic medical record.
• Works in the community at partner facilities or at participant homes or other venues, as necessary.
• Demonstrates an understanding of the importance of clear, thorough documentation as crucial to good participant care; completes and enters accurate, thorough participant documentation in the electronic health record; enters documentation for assessments, orders, and notes within required time frames.
• Performs other related duties as required and assigned.

• Ability to maintain confidentiality
• Ability to prioritize tasks and meet project deadlines
• Proficiency with MS Office Suite or similar software
• Dependable and punctual with ability to maintain consistent attendance
• Ability to read, write and comprehend English
• Ability to maintain sound judgement under stress and communicate effectively
• Ability to read, interpret,…